Medical Release Form
Each student must fill out the information below completely. This form will be kept on file for one (1) year as a medical release. If your medical or insurance information changes, please contact the Student Ministry Office or submit another online form to update your information.
Student's Name
*
First Name
Last Name
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
School
*
Grade
*
Infant/ Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List any Allergies your Child has:
Parent / Guardian Name
*
First Name
Last Name
Cell Phone Number
*
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Emergency Contact (If parents cannot be contacted)
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
I hereby give my permission, for myself or my child, to participate in an activity organized by the Valley Student Ministry /ValleyBaptist Church. I hereby release, hold harmless and absolve Valley Baptist Church, their officers, staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations,singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Valley Baptist Church staff or any adult counselor acting on behalf of Valley Baptist Church with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate} licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child's medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that Valley Baptist Church may tape or photograph my child and record his or her Voice during their participation in the activity. I agree that Valley Baptist Church will be able to use them, in whole or in part. whether In original or modified form in any manner or media, Including without limitation, for the purpose of advertising, promoting, and publishing theValley Baptist Church whether doing the activity or thereafter. I hereby release and discharge Valley Baptist Church and an affiliated entities from any and all claims, demands, or causes of action that I shall in connection with the use and exercise of the rights granted in this release.
Signature
*
Parent / Guardian
Submitted Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: