Medical Liability

Child's Name(Required)

First Last

Age(Required)

Date of Birth(Required)

Address(Required)

Street Address City State ZIP / Postal Code

Emergency Contact(Required)

First Last

Emergency Contact Phone(Required)

Family Doctor

Family Doctor's Phone

Health History

Check all that apply.

Allergies

Insect Stings

Drugs

Other

Explain 'Other'

Other Conditions

If you checked any of the above, please give details.

(i.e. include normal treatment of allergic reactions)

Any Swimming Restrictions:

Yes

Any Activity Restrictions:

Yes

Explain restrictions:

Also list the names and dosage of current medications.

Insurance Company Name

Our church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church-related activity.

Your Insurance Company's Name

Policy Number

Group Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Consent(Required)

I agree to the Emergency Procedure and the Liability Release.

EMERGENCY PROCEDURE: In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary.

LIABILITY RELEASE: Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By submitting a photo of your government issued identification and this form in its entirety, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold this church or its employees or volunteer assistants or its individual members liable for damages or injuries to the person or property undersigned. The parents or guardians understand that they are submitting for the minor listed on this form, and the submission is for both a medical and liability release.

Today's Date(Required)

Upload a jpg, png, or pdf of the Parent/Legal Guardian's Driver's License.(Required)

The parent or guardian has attached a copy of their driver’s license evidencing their signature on this form in lieu of additional witnesses.

Max. file size: 50 MB.

Phone

This field is for validation purposes and should be left unchanged.

FBC of Owensboro, Inc. Medical and Liability Release Form

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First Baptist Owensboro

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