Evangel Youth Medical Release and Permission Form

This form should be completed by a parent or legal guardian of the student(s).

Your name *

Email address *

Personal Information

Student Name *

Gender *

Age *

Birthdate *

Height

Weight

Allergies/Medicine Being Taken *

Add a Second Student

Family Information

Parent/Guardian Name *

Address *

Family Physician

Physician Phone Number

Emergency Contact

Please list two numbers if possible below (home, work, cell, etc.).

Name *

Relationship *

Phone number *

Phone number

Medical Insurance Coverage

Company *

Policy # *

Group # *

Agency Phone Number *

Agency Address

Insurance Card

Please provide a picture/copy of the front and back of your insurance card.

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

Permission and Release *

By CHECKING:

I am giving my permission for the above-named student(s) to join the young people of Evangel Baptist Church in activities (including transportation) under the authority and supervision of Evangel Youth Leadership. I, as the Parent/Guardian, agree to assume complete responsibility for any injury, accident, or illness which may occur during or arising from my and my family's participation in Evangel Baptist Church events.

I state that my student(s) is in proper physical condition to participate in Evangel Youth activities. I also authorize that the information provided is truthful and correct. Furthermore, in the event of an emergency, I give my consent to any Evangel Baptist Church staff member or volunteer to, as an agent for me, consent to any x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon or dentist licensed to practice under the laws of his/her state. I expect to be contacted as soon as possible.

In consideration that my student(s) has voluntarily agreed to participate, I hereby, for myself, my heirs, executors, and administrators, successors, and assignees release, forever discharge and hold Evangel Baptist Church the sponsor for this event, its agents, representatives, successors, and assignees, harmless from any and all claims for damages, injuries or sickness suffered by my student(s) or myself by his or her participation. In the event of injury or illness, I will be completely responsible for any and all treatment costs. I absolve Evangel Baptist Church, and/or church personnel from liability in acting on my behalf. I also authorize the administration of basic first aid, and in the event of need provide an appropriate dosage of over-the-counter medications (ex. Tylenol, Advil, Tums, etc.).

I hereby release Evangel Baptist Church to use photos and/or videos of my student(s) in promotional material.

I give permission for Evangel Baptist Church staff and volunteers to counsel, in an appropriate setting and/or as necessary, without a license.

Notes/Comments/Questions

Date of Submission *

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