FIRST BAPTIST CHURCH, COLUMBUS, GA
Medical Care, Emergency Contact Information & Photo Release
(Valid June 1, 2010 – May 31, 2011) (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 Date 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:_________________________________
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