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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