Fillable Medical Release Form - Summer Creek Baptist Church printable pdf download

MEDICAL RELEASE FORM

12159 W. Lake Houston Pkwy

Houston, TX 77044

(281) 458-7800

I hereby give my permission for ____________________________________________________ to take part in various church sponsored youth trips, outings,

(name of child)

and camps. I further give my permission for the church representatives or sponsors of the trips so secure needed medical treatment in the event that I cannot be

reached for such permission. I release the church and/or the church representatives or sponsors from liability for accident or injuries on the activities.

I further understand and agree that in the event that the above named son/daughter be involved in activities that violate or compromise the rules, polices, or

purposes of Summer Creek Baptist Church, I will pay and accept full responsibility for release of my child to my custody and care.

Child’s Street Address ______________________________________________________

Child’s Phone _________________________________

Child’s City/ST/Zip: ________________________________________________________

Child’s Date of Birth ____________________________

IN CASE OF EMERGENCY, PLEASE CONTACT:

Parent or Guardian: ________________________________________________________

Cell Phone: ___________________________________

Parent or Guardian: ________________________________________________________

Cell Phone: ___________________________________

Doctor: __________________________________________________________________

Office Phone: _________________________________

Friend or Relative: _________________________________________________________

Cell Phone: ___________________________________

Known food/drug allergies: _______________________________________________________________________________________________________

Medication taken regularly: _______________________________________________________________________________________________________

_______________________________________________________________________________________________________



Swimming: My child is a

non-swimmer

fair swimmer

good swimmer

Date of last tetanus shot/booster: ___________________________

Medical Insurance Company: _________________________________________________

Phone: _______________________________________

Group Number: ____________________________________________________________

Policy Number: ________________________________

I understand that my signature conveys the following:

My authorization for the adult leader to obtain necessary medical treatment for minor listed above.

I knowingly release, absolve, indemnify, and hold harmless Summer Creek Baptist Church of Houston, Texas from all claims that might result

from any injury or death of minor listed above.

Should medical treatment be required, I agree to pay all medical/hospital care costs, either directly or through my personal health and accident

insurance policy.

Signature: _________________________________________________________________

Date: ________________________________________

STATE OF TEXAS

County of HARRIS

Before me, a Notary Public, on this day personally appeared _________________________________________________ known to me to be the person whose

name is subscribed above, and acknowledged to me that he/she executed the same for the purpose therein expressed.

Sworn and subscribed before me this __________ day of ________________________________, year ______.

(PERSONALIZED SEAL)

_____________________________________

Notary Public’s Signature

Medical Release Form - Summer Creek Baptist Church

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