Madison Baptist Church Child Participation And Medical Release Form printable pdf download

Madison Baptist Church Child Participation And Medical Release Form

MADISON BAPTIST CHURCH

CHILD PARTICIPATION AND MEDICAL RELEASE FORM

(Please Print or Type)

Child:

___________________________________________________________________

Child’s D/OB:

___________________________________

Age:

__________________

Parent/Guardian:

___________________________________________________________________

Address:

___________________________________________________________________

City:

__________________________

State: ________ Zip:

________________

Mobile:

________________

Work

________________

Home

________________

Medical Authorization

Parent/Guardian hereby grants Madison Baptist Church, including its authorized staff and volunteers,

permission to allow Child to receive emergency medical care for any injury or illness occurring while Child

is participating in any Church event or activity, whether on the Church’s premises, or elsewhere.

Medical Information

The following includes a complete list of all medications, allergies, and medical conditions of Child:

Medication:

________________________________________________________________

Allergies:

________________________________________________________________

Family Doctor: _________________________________

Phone: ___________________

Address:

_______________________________________________________

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Madison Baptist Church Child Participation And Medical Release Form