MEDICAL RELEASE FORM (2026)

MEDICAL RELEASE FORM (2026)
Name of Student/Child
Birthdate

MonthDayYear
Date
Grade
Address
Parents or Guardians names
Parents or Guardians Phone #
Format: (000) 000-0000.
Alternate #
IN CASE OF EMERGENCY:
Emergency Contact name
Emergency Contact Phone #
Format: (000) 000-0000.
Doctor
Dr. Phone
Format: (000) 000-0000.
HEALTH HISTORY
Allergies
Other conditions
Medications currently taking
Any activity restrictions?
If yes, please explain
Do you have health insurance?
If yes, name of Ins. Company
Policy Number
Please Note: Our church insurance is 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.

The Rising is a ministry of the First Baptist Church of Prineville, OR. Every activity of The Rising is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precautions, unforeseen events can occur. By signing this form, you, the parent or guardian of the student, agrees to assume and accept all risks and hazards inherent in these activities. You also agree not to hold First Baptist Church of Prineville along with any of its employees or volunteers liable for damages, losses, or injuries to the person or property undersigned. You understand that you are signing for the minor listed on this form and the signature is for both a medical and liability release.

"In the event 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 the above-named student as deemed necessary."

This authorization shall remain in effect through December 31, 2026.
Parent or guardians signature
MonthDayYear
Date

PERMISSION TO CONTACT
I, (Parent or guardians first and last name):

First NameLast Name
Give permission for First Baptist Church of Prineville's The Rising staff members to contact:
Students first and last name:

First NameLast Name
Through phone and text messages concerning The Rising events and details that may need to be communicated during the week/weekend.
Parent or guardians signature
MonthDayYear
Date

MEDIA RELEASE
I, (Parent or guardians first and last name):

First NameLast Name
Give permission for The Rising to use photographs that may include my child for promotional or informational purposes.

These may include:
- Printed media (misitry reports, flyers, camp brochures etc).
- Websites or social media pages for The Rising.
- Visual presentations.
Name of student

First NameLast Name
Parent or guardians signature
MonthDayYear
Date
Should be Empty:

MEDICAL RELEASE FORM (2026)

IN CASE OF EMERGENCY:

HEALTH HISTORY

PERMISSION TO CONTACT

MEDIA RELEASE