Youth Medical Release Form and Medical Information 2020
Please fill out this form and click submit.
Student's Name
*
Parent/Guardian Full Name
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I The Parent/Guardian named above, authorize that the staff and/or adult volunteers of the First Baptist church may seek or provide medical assistance for the child named above, in the case of an emergency during any regularly sponsored youth event or activity from January 1, 2020 - December 31st, 2020
*
Please select one option.
Agree
Select Option
Agree
Medical Information
Name of Student
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Date of Birth
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Personal Doctor
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Personal Doctor Phone
*
Medical Insurance Company
*
Medical Insurance Policy Number
*
Parent/Guardian Contact Information
Name
*
Cell Phone
*
Home Phone
Work Phone
Other Emergency Contact
Name
*
Cell Phone
*
Home Phone
Work Phone
Medical History
Allergies to Food
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Allergies to Medication
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Current Medications (Include vitamins, herbs, and "As Needed" Medications)
*
(All medications brought must be labeled with the drug name, student's name, dose size, and frequency of us.)
Submit
Description
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