Permanent Medical Release
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1(PLEASE PRINT)
University Baptist Church * Houston, TX
Name
Phone
Address
Email
City
State
Zip
Birth Date
Age
Grade
School
Church Where You Regularly Attend
Parent’s Name
Phone
Parent’s Work Phone
Parent’s Cell Phone
In case of emergency notify
Phone
Family Physician
Phone
Family Insurance Co.
Policy #
Name of Insured
Immunization Date: Tetanus
List Allergies
List any permanent prescription drugs your child is presently taking; state frequency and dosage:
Other Medical Information
Medical Care & Medical Information Authorization
TO THE ATTENDING PHYSICIAN, HOSPITAL AND STAFF:
Permission is hereby granted for you at the discretion of the staff and/or sponsors of UBC to perform necessary care for the welfare
of my child until such a time as you are able to reach us personally.
_______________________________
_____________________________
____________________________
Parent/Legal Guardian: Printed Name
Signature
Date
______________________________
_____________________________
____________________________
Witnessed by: Printed Name
Signature
Date
*Must be natural or adoptive parent, or legal guardian
Liability Release
.
I,
, do hereby release, absolve, indemnify and hold harmless
UBC, the organizers, sponsors, and supervisors from any and all loss, injury, or other damage to me or other named persons arising out of our
participation in church sponsored events. I likewise release from responsibility any person transporting people (including my children) to,
during, and from the activities. I also acknowledge that insurance UBC may carry is secondary to my personal insurance.
Signature:____________________________
_______________________________
(Name & Relation to Child)
Date
*Must be natural or adoptive parent, or legal guardian
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