Children’s Medical Release

Child Information

Child's Name Age
Grade Level
Address City Zip Code

Emergency Information

Mother's Name Phone Cell E-mail
Father's Name Phone Cell E-mail
Alternate Name Phone Cell E-mail Relationship
Medical Insurance Policy#
Family Physician Phone
Family Dentist Phone
Hospital Preference

Check the following areas of concern for this student.

1. For your child’s safety and our knowledge, is your student a

2. Does your child have allergies to

3. Does your child suffer from, or has ever experienced, or is being
treated currently for any of the following:
Explain other:

4. Date of last tetanus shot:

5. Does your child wear:

6. Please list and explain any major illnesses the child experienced during the last year.

7. Should this child’s activities be restricted for any reason? Please explain:

Participant Consent Form:

Description and Location of Activities: All activities on and off the grounds of the Denman Avenue Baptist Church.

Consent Agreement:

I, the undersigned, as a parent or legal guardian of the above named minor, hereby give my consent for the above named person to participate in the activities described above. I know of no physical or emotional condition which would limit the participation of this person in the activities except as listed on the Medical Release Form. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.

If this Participant should, for any reason, require any emergency medical or surgical treatment during the activities, I authorize such physician or medical staff as you may designate to carry out the necessary treatment. I further authorize you to transport or arrange for the transport of this person to the Emergency Room of the nearest hospital and I authorize the hospital and its medical staff to perform any treatment deemed necessary by them for the well being of this person.

It is understood, however, that if hospitalization or treatment of a serious nature is required, every effort will be made to contact me by telephone for permission.

I hereby release volunteers and employees of the Denman Avenue Baptist Church from any and all liability for any and all injuries, illnesses, or other damages that may be incurred by the above named person, or his or her personal property, during the course of any and all activities, including transportation to or from activities. I have read and fully understand the provisions of the above release.

Consenting Parent Name: Date:

I agree to the above Consent Agreement