Medical Release

FBC Student Ministry - Year 2010 Activities

Please complete this medical release form, which will be e-mailed to Pat Drown. If you wish to print it out you may turn it in to the student office. We will keep it on file for one year. If you need to update the form at any time, you may do so in the Student Office. This is only a medical release form. Your student will be asked to fill out a registration form for each individual event they attend. Thank you.

Grade in Spring 2010: Grade in Fall 2010

School    Age:

Male    Female

Student's Name:

Date of Birth (mm/dd/yyyy):

Student's Address: City: Zip:

Student's Phone Number:

Student's Email:

Emergency Contact:

Contact Address: City:

Zip:

Contact Phone: Work Phone:

Cell Phone: Other Phone:

Insurance Company:

Policy Number of Person Attending Event:

Medical Problems:

Allergies:

Current Medications:

I hereby give my permission for to receive emergency medical and/or dental treatment from a physician in the event of illness or injury. I will not hold the staff, counselors, or First Baptist Concord responsible for any incident or accidents that occur to my youth resulting from reasonable and prudent activities or counselor action.

I hereby give permission for my student to be photographed or video taped for the student ministry website or to be used in future student ministry publications such as summer camp brochures, calendars, etc.

Parent Signature: Date: