Medical Release Form

Participation and Medical Release Form

Name of Event

Name of Student (or adult volunteer) Attending

First Name

Last Name

Phone Number (phone and sms capable preferred)

(###)

###

####

Email of Student (or adult volunteer)

Age of Student

Grade

Date of Birth

YYYY

Address of Student's (or adult volunteer) Residence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1st Parent | Guardian

First Name

Last Name

Relationship to Student

Best Phone Number

(###)

###

####

Best Email

2nd Parent | Guardian

First Name

Last Name

Relationship to Student

Best Phone Number

(###)

###

####

Best Email

Emergency Contact

First Name

Last Name

Phone of Emergency Contact if different than already listed Parent | Guardian

(###)

###

####

Family Doctor

First Name

Last Name

Doctor's Phone Number

(###)

###

####

Insurance Company

Insurance Phone Number

(###)

###

####

Comments Regarding Insurance

Insurance Policy and/or Group Number

Insured Name

First Name

Last Name

Medication Being Taken With Dosage

List Any Known Allergies/Physical Problems

Date of Last Tetanus Shot

YYYY

Student May Be Administered

Check All That Apply

Tylenol

Advil

Benadryl

Pepto Bismol

First Aid Cream/Spray

Neosporin

Date of Signature

YYYY

Parent | Guardian Signature (please read the statement below fully)

First Name

Last Name

**By submitting this form, you consent to the participation in the above referenced event conducted under the sponsorship of First Baptist Church, Forsyth County, Georgia. As parent, I hereby authorize and consent to any emergency medical treatment, including but not limited to X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to my child on the advice of a licensed physician, surgeon, anesthesiologist, dentist, or other qualified medical personnel acting under their supervision. I fully assume responsibility for any and all medical expenses which may be incurred.

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above, the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the event. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the event or during transportation to and from the event, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “event sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the event sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the events sponsor, the participant, or otherwise.

If a dispute over this agreement or any claim for damages, arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the event sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.