MEDICAL RELEASE FORM
Student’s Name:__________________________________ Parent’s Name:____________________________ _
Address: ________________________ City:_______________________ State:___________ Zip:__________
Phone:_________________________ Other Phone: _____________________________
PARENT: I, _____________________, the undersigned parent or person having legal custody or the legal guardian of above named
minor give permission for the above named minor to participate in the _____________________________________________________
and do hereby authorize Travis Duke, Children’s Pastor of First Baptist Church of Pearland, or any sponsor appointed by Travis Duke to
consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care to be rendered to the
above named minor under general or special supervision and upon the advice of a physician, surgeon, or dentist licensed under the laws of
the state they practice in. In giving this consent I recognize and understand that in situations where the named minor requires immediate
medical or hospital care it may not be possible to contact me, in such situation I will not be able to knowledgeably evaluate and chose
among the available alternative treatments or procedures, if any, or to evaluate the risk attenuate upon each, and the risk attenuate to
forgoing all treatment in such situations, I authorize a physician, surgeon, or dentist to exercise his professional judgment and assess the
risk incident to and chose the necessary treatment from any available alternatives and to render such care and perform such treatment as
he in his professional judgment determines to be necessary for the health or safety of the above named minor. I also agree to reimburse
any expenses not covered by the church’s insurance. I will not hold the church or any of the workers responsible for any illness or injury
to my child.
_____________________________________________________
(Signature of parent or legal guardian)
(date)
MEDICAL INFORMATION
Name of Medical Insurance Company _______________________________ Policy Number _____________________________
Date of last tetanus shot _____________________________________________________________________________________
Any health problems, limitations, etc? _________________________________________________________________________
Any allergies, or medicines, drugs, or shots person is allergic to: ____________________________________________________
________________________________________________________________________________________________________
Is the youth bringing any medication on the trip? (be sure the medications are labeled as to the contents and youth’s name) ______
________________________________________________________________________________________________________
If Yes, give name of medication(s) and directions for administering _________________________________________________
________________________________________________________________________________________________________
Person(s) to notify in the event of serious illness or injury:
Name: ________________________________ Address: ___________________________________________________
City: _________________________________ State________________ Phone ______________________ Other
Phone______________
_____________________________________________________
(Signature of parent or legal guardian)
(date)