Permission and Medical Release Form - Clover Sites



Children Ministry Permission and Medical Release Form

I, ______________________________________________, give my permission for my

(please write parent/guardian full legal name)

(son/daughter), _________________________________________ to participate in

(please write his/her full legal name)

Children Ministries activities from Lakeside Baptist Church located in Lakeland, Florida.

Emergency Medical Information

Participant Information:

Name_____________________________________________ Birthdate_________________

Home Address_______________________________________________________________

Social Security # __________________________ home phone________________________

Cell phone (1) _________________________ Cell phone (2) __________________________

Please list any medical conditions, injuries, or allergies and/or medication the participant may be on:___________________________________________________________________

____________________________________________________________________

In case of emergency, please contact:

Name______________________________________ phone___________________

Name______________________________________ phone__________________

Physician Information:

Physician____________________________________ phone_________________________

NOTE: We require each participant to be covered by sufficient health/accident insurance.

Company__________________________________________ Effective date______________

Group I.D. # _________________________________

Medical Release: In the event of an emergency, in which you are unable to reach me (parent/guardian), in case of injuries, accidents, or illness, I give my permission for treatment deemed necessary in consultation between attending emergency physician and the Event Leader for Lakeside Baptist Church. I also release Lakeside Baptist Church and its program staff of liability in the case of accidents or injuries to ____________________________________ while attending any event or trip.

_____________________________________

(Signature of parent/guardian)

_________________

(Date)

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