Microsoft word - medical release form.docx

2013 Student Ministry Event Permission Form - Cumming Baptist Church
I________________________ give ________________________ permission to participate in student ministry sponsored events during 2013. In case of emergency, I give Chad Ireland or the person placed in charge of my child permission to have my child treated. I will not hold the individual, the attending physician, or Cumming Baptist Church, Cumming, GA responsible. Medication currently taking:____________________________________________ Medication allergic to:_________________________________________________ Any Food Allergies:__________________________________________________ Please check the following medications that you give your permission for your child to take should they be needed: ___Tylenol/Ibuprofen—for headache, aches, fever, cramps ___Mylanta, Maalox—for upset stomach ___Dramamine—for prevention of nausea ___Benadryl—for allergic reactions or cold symptoms ___Tigan, Phenergan suppository—for excessive vomiting ___Murine Eye Drops—for irritated eyes List any physical, emotional, or mental handicaps so leaders can be sensitive to special needs. This information is confidential (explain on back if necessary). Insurance Carrier:______________________________Policy No:____________________ Numbers where you can be reached: Home:____________________Work:_____________________Cell:___________________ ⇒ My child and I understand what is expected regarding behavior. Bad behavior will result in forfeiting the privilege of participation in the next trip and being sent home on this trip, at the expense of the parent or guardian. I understand that there are to be no electronic devices (mp3 players, ipods, gaming devices, etc.) unless permission is expressly given to bring such devices. I also understand that cell phones may be collected on any trip and given back as we near home. No drugs, alcohol, or weapons of any kind will be allowed. Parent Signature__________________________________Date__________________ Participant Signature______________________________Date__________________ Student’s Birthdate_________________ Student’s SSN:___________________ Student’s Mailing address:_____________________________________________________ ⇒ I, the parent or guardian of the above individual, acknowledge that the participation in youth activities sometimes necessarily involves risk of physical injury. I further acknowledge that the programs of Cumming Baptist Church Student Ministry are primarily administered by volunteers and parents who give their time rather than paid professionals. By signing this form on behalf of the above named individual and permitting the voluntary participation of said individual in its youth programs, I hereby release, discharge, and hold harmless Cumming Baptist Church, its employees, volunteers, agents, and other representatives from any claims arising out of or relating to any physical injury that may result to said individual while participating in Cumming Baptist Church Student Ministry sponsored activities. ⇒ I further understand that pictures, videos, or audio of said individual may be used at the discretion of Cumming Baptist Church in promotional video/audio/publications/website/etc. without notification. Dated this _______day of __________________2013.
**Notice: Unless revoked by giving reasonable notice, this medical authorization is valid for one year (specifically the year 2013) and
will be maintained at the Cumming Baptist Church offices by the church staff.



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