Student Medical/discipline Form printable pdf download

Grade

Completed

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 ______________________

Student Medical/discipline Form