Student Medical/discipline Form


May 2016
Student Medical/Discipline Form
Name ___________________________________________ Cell Phone # ___________________________
Mailing Address ______________________________________ City _________________ Zip ___________
Email ___________________________________________________________________________________
Birthday __________________________________________ T-Shirt Size ____________________________
Parent Name(s) ____________________________________ Parent Cell # ____________________________
Current Medications _______________________________________________________________________
Current Health/Medical Conditions ___________________________________________________________
Allergies ________________________________________________________________________________
Family Doctor ________________________________________ Doctor’s Phone # ____________________
In case of emergency contact _____________________________ Phone# ___________________________
Second emergency contact _______________________________ Phone# ____________________________
Medical Consent
I hereby give permission for the staff and/or youth workers of Willowbrook Baptist Church to obtain any necessary
medical care for my child. Furthermore, I release Willowbrook Baptist Church and all of its representatives of
any liability regarding such a matter. I understand that this medical waiver will be effective only for events of
the school year in which it is signed. I also agree to contact the student ministry office if my child’s medical
information should change within that school year.
Parent/Guardian Signature _________________________________________ Date ____________________
Discipline Understanding
I understand that my child (I) will be expected to obey all rules and guidelines set forth by Willowbrook Baptist
Church for their trips and events. I further understand that if my child (or I choose) chooses to not adhere to these
rules and guidelines that (I) he/she will be dismissed from the trip/event and sent home at my (parent/guardian/
my) expense.
Parent/Guardian Signature __________________________________________ Date ___________________
If over 18
Student Signature ______________________________________________ Date ______________________


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