Medical Release Form

Name of Student Attending *
Name of Student Attending
Phone Number (phone and sms capable preferred) *
Phone Number (phone and sms capable preferred)
Date of Birth *
Date of Birth
Address of Student's Residents *
Address of Student's Residents
1st Parent | Guardian *
1st Parent | Guardian
Best Phone Number *
Best Phone Number
2nd Parent | Guardian *
2nd Parent | Guardian
Best Phone Number *
Best Phone Number
Emergency Contact *
Emergency Contact
Phone of Emergency Contact if different than already listed Parent | Guardian
Phone of Emergency Contact if different than already listed Parent | Guardian
Family Doctor *
Family Doctor
Doctor's Phone Number *
Doctor's Phone Number
Insurance Phone Number *
Insurance Phone Number
Insured Name *
Insured Name
Date of Last Tetanus Shot *
Date of Last Tetanus Shot
Student May Be Administered *
Check All That Apply
Date of Signature *
Date of Signature
Parent | Guardian Signature *
Parent | Guardian Signature

**By submitting this form, you consent to the participation in the above referenced activity 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.