Medical Waiver/release Form

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MEDICAL WAIVER/RELEASE FORM
NOTICE: This form must be completed and mailed to the Youth Ministries Office for Students in order for he/she to be able to
participate in a Georgia Baptist Convention/Youth Ministries Office sponsored activity or event. This form must be signed by a
parent or guardian and notarized in the spaces provided.
Participant’s Information
__________________________________________________________________________________________________
Last
First
Middle
Prefer to be called
__________________________________________________________________________________________________
SS# (for Ins. Purposes only – these forms are destroyed after Impact)
Age
Date of Birth
Church
__________________________________________________________________________________________________
Street Address
City
State
Zip
**IN CASE OF AN EMERGENCY, NOTIFY ONE OF THE FOLLOWING IN THE ORDER LISTED**
1. ________________________________________________________________________________________________
Name
Relationship
Work Phone
Home Phone
Cell Phone/Pager
2. ________________________________________________________________________________________________
Name
Relationship
Work Phone
Home Phone
Cell Phone/Pager
Parent/Guardian Information
1. _______________________________________________________________________________________________
Last
First
Middle
Relationship
_______________________________________________________________________________________________
Street Address
City
State
Zip
_______________________________________________________________________________________________
Church
Work Phone
Home Phone
Cell Phone/Pager
2. _______________________________________________________________________________________________
Last
First
Middle
Relationship
_______________________________________________________________________________________________
Street Address
City
State
Zip
_______________________________________________________________________________________________
Church
Work Phone
Home Phone
Cell Phone/Pager
INSURANCE CARD INFORMATION MUST BE COMPLETE!!!!
Participant’s Name: ________________________________________
If you do
not have
Participant’s ID#: __________________________________________
insurance,
please
Name of Insurance Company: ________________________________
check here:
Group Name: _____________________________________________ Group #: _____________
Employee Name (Parent or Guardian): _______________________________________________
Employee SS# _______________________ (These forms are destroyed after Impact)
Claims Submission:
Address: ________________________________ City, State, Zip ________________________
Phone # for eligibility/inquiries: _________________________________

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