Medical Release Form printable pdf download

Revised January 2015

MEDICAL RELEASE FORM ISTROUMA BAPTIST CHURCH

Form #2 (Page 1 0f 2)

Medical Release Form

Each participant attending any or all Istrouma Baptist Church scheduled (retreats, conferences, camps, etc.) must

complete this form. This form will be kept on file in the Istrouma Baptist Church office and will remain effective for any

authorized Istrouma Baptist Church event this person participates in until said participant’s parent or guardian nullifies

this form via written request. NOTE: This form must be notarized by a legal official before two (2) witnesses.

Name ___________________________ Date of Birth ____________________ Grade ______

Street Address _______________________________________________________________

City __________________________ State ___________ Zip Code ______________________

E-mail Address ___________________________________ Phone # _____ _____ _________

Are you a member of Istrouma Baptist Church? ☐ Yes ☐ No

Primary Physician ________________________________ Phone # _____ _____ __________

Health Insurance Company ________________________Policy Number _________________

Insurance Company Phone # ____ _ _____ _____________Group # ____________________

Do you have any special health issues Istrouma Baptist Church should be aware of? ☐ Yes ☐ No

If so, please explain:

MEDICAL HISTORY:

Immunizations: ☐ Tetanus/Date

☐ Polio Booster ☐ Measles ☐ Mumps

Other:

CHECK BOX BELOW IF YOU HAVE EXPERIENCED...

☐ Asthma ☐ Sinusitis ☐ Bronchitis ☐ Kidney issues ☐ Heart issues ☐ Dizziness ☐ Stomach issues ☐ Hay

Fever ☐ Sleepwalking ☐ Epilepsy ☐ Diabetes ☐ Fainting Spells

☐ Other

List medicines taken on a regular basis (including all prescriptions):

Allergies ☐ Foods

☐ Penicillin or other drug (name)

☐ Insect stings/bites (name)

☐ Poison sumac, oak, ivy, etc

Previous surgical operations or illnesses

Do you swim? ☐ Yes ☐ No ☐ Advanced ☐ Beginner

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Medical Release Form