First Baptist Church
Friday, April 18, 2014
Come Home to First Baptist

Medical Release Form

                                                                      FIRST BAPTIST CHURCH, COLUMBUS, GA
Medical Care, Emergency Contact Information & Photo Release
(Valid Thru – December 31, 2014) (Please update as necessary)
 
 Name________________________________________________Birth Date_______________________________
 
Address_____________________________________________________________ ________________ ________
 
Phone (H)________________ (W)__________________(cell)________________
 
 Passport (attach copy)_____________________T-Shirt Size(circle) YS-YM-YL-AS-AM-AL-AXL-AXXL
                                                                                                                 
Alternate Emergency Contact________________________________Phone________________________________
 
 Physician__________________________________________Phone_____________________________________
 
Known Allergies (medicine, food, etc.)_____________________________________________________________
 
Describe past serious illnesses or hospitalization, with dates_____________________________________________
(Use back if necessary.)
 
List Medicines Taken (use back if necessary)_________________________________________________________  _____________________________________________________________________________________________
 
Date of Last Tetanus Injection_____________________________________________________________________
 
Describe all physical conditions or illnesses, which could affect  participation in the programs or the proper medical treatment (diabetes, epilepsy, poor blood clotting, etc.)____________________________________
 
Health Insurance: Company______________________________Policy Number____________________________
 
Beneficiary’s name ____________________________________(Please Attach Copy of Insurance Card )
 
If under 18 please list:
     Mother’s Name___________________________Phone (H)______________ (W)____________(cell)________
 
      Father’s Name____________________________Phone (H)______________(W)____________(cell)________
 
 Emergency Medical Treatment/Photo Consent
(Must be signed in the presence of a notary)
                I hereby give the Designee of First Baptist Church events permission to provide first aid care for me or my child,_______________________________________. I hereby authorize First Baptist designee to transport me or my child to the emergency room of the hospital(s) listed below, and I hereby grant my consent for the hospital and its medical staff to provide me or my child with emergency medical treatment which a physician deems necessary (including anesthesia). If I have not specified any hospital(s) below, I or my child may be taken to and cared for at the nearest hospital. I agree to accept financial responsibility for all medical expenses incurred.
Hospital__________________________________Hospital________________________________________________________
Nearest Hospital________
 
Photos and likenesses of the above may be utilized for historical and or advertising/public relations for First Baptist Church without remuneration for said likenesses.
 
______________________________________                   
Signed Parent/Guardian              Date                                       
 
State of_____________________________County of______________________________
 
The foregoing Consent was acknowledged before me this____________day of_____________, 20____, by
_______________________and________________
                                                                              Notary Public___________________________________________
                       (Notary Seal)                                   My Commission Expires:_________________________________
 
To print, highlight the document, then right click and push print.