SMBC Trip Permission/Medical Release
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Email *
Student Name *
Gender *
Date of Birth *
Address *
City *
State *
Zip Code *
Student Cell # *
T-Shirt Size *
Parent/Contact Name *
Relationship *
Contact Phone # *
Primary Physician *
Physician Phone # *
Insurance Company *
Policy Holder Name *
Policy # *
Medical Conditions *
Allergies *
Medications and Dosages *
Parent Name *
Full Name, by typing your name here you are agreeing to the following statement:I give <<Student Name>> permission to participate in any activity that Summers Missionary Baptist Church (SMBC) is sponsoring for the 2021 calendar year.  Furthermore, I agree not to hold any representative of SMBC, absent or present, any camp owner or staff, or any facility owner or staff responsible for the negligence on the part of the above referenced student or for any injury or injuries that may occur while on any said activity.  I agree to pay for any destruction and negligent act that may occur while on an activity, and to pay for transportation to send the student home from any activity they are attending.  I give permission for medical services to be secured as well as anesthesia for my child’s well being and to reimburse SMBC for any costs for medical services rendered.  I also understand that as a participant that my child may be photographed or videoed.  These pictures or videos may be used to publicize the activities of SMBC.  By signing below you agree to abide and support the above statements.
Date Completed *
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