Medical Release Form For Minors Parent Guardian Consent printable pdf download

Medical Release Form for Minors

ParentGuardian Consent

Name of Participant __________________________________

Date of Birth __________________

Address _______________________________________

Phone _______________________

City ___________________________________

State ______________

ZIP ________________

Name of Parent/Guardian _____________________________________________________________

PERMISSION

I, _______________________________________________________

(parent/guardian) hereby give

permission for _____________________________________________

(hereinafter referred to as

"the student") to travel with ____THE WINSTON COUNTY BAPTIST ASSOCIATION_________

(hereinafter referred to as "the association") to ______South Africa _______________

(destination)

during the following dates __________________________________ .

[ ] I do hereby verify that the below information is correct and I do hereby grant permission for the

association to obtain medical attention in case of sickness or injury to the student.

[ ] I hereby grant permission for an attending physician or hospital to perform whatever care deemed

necessary by the association for the welfare of the student until such time as you are able to

reach me personally.

[ ] I also hereby release, absolve, indemnify, hold harmless, and forever discharge the association,

the organizers, sponsors, and supervisors from any and all claims, demands, actions or cause

of actions, past, present, or future arising out of injury or damage while participating on this trip.

[ ] I assume all risks and hazards incidental to the conduct of the activities and transportation to and

from the area. In case of injury to the student, I hereby waive all claims against the organizers,

the sponsors, or any supervisors appointed by them. I likewise release from responsibility any

person transporting the student to and from the activities.

[ ] I agree to provide medical insurance for my student(s) who are participants on this trip.

Signature of Parent/Guardian _________________________________

Date ___________________

MEDICAL AND INSURANCE INFORMATION

Family Insurance Company _____________________________ Policy # ______________________

Family Physician _____________________________________

Phone _______________________

Check if applicable and give appropriate explanations below if needed:

[ ] Allergies

[ ] Asthma

[ ] Bronchitis

[ ] Diabetes

Medical Release Form For Minors Parent Guardian Consent