Child Medical Release Form (Page 2 of 2) in pdf

Fathers Name: ______________________________________________

Phone – Cell: _____________________ Home: _____________________ Work: __________________________

Address (If different from above): _______________________________________________________________

Mothers Name: ______________________________________________

Phone – Cell: _____________________ Home: _____________________ Work: __________________________

Address (If different from above): _______________________________________________________________

Person(s) to be reached if parent/guardian cannot be contacted:

Name: ____________________________ Phone: (_____) ___________________ Relationship: ______________

I understand that only parents/guardians are authorized to pickup students. Should other arrangements need to be

made, please provide written authorization and a copy of the party’s driver license and contact information. ______

I grant permission for pictures or videos of my student to be used on the church’s website and/or facebook. ______

I, ___________________________, do hereby verify that the information contained on this form is correct and I do hereby

release and forever discharge First Baptist Church of Alachua (FBCA) and sponsors from any and all claims, demands,

actions or cause of action, past, present or future arising out of any damage or injury to my child whose name is listed

previously. My permission is granted to the FBCA staff or FBCA sponsors in charge to obtain necessary medical attention in

case of sickness or injury to my child.

Dated this _____ day of ______, 20___ in the State of ________ and the County of __________________________

Signature: ______________________________________________________________________________________

The remainder to be filled out by Notary Public

On this _____ day of _______, 20___ personally known by me, and in my presence executed the within and foregoing

permission and release form. Witness my hand and official seal.

My commission expires _____________________.

______________________________Notary Public

(See Other Side)

Child Medical Release Form Page 2