Medical Release Form 2024
I certify that the above-named child or student is my child or my legal ward and resides with me. In the event he/she becomes ill, is injured, or for any reason requires medical treatment while attending a Harvest Baptist Church event or activity. I do hereby consent to any and all medical or surgical treatment, including anesthesia and operations, which may be deemed advisable by any qualified physician selected by agents or officials of Harvest Baptist Church. In the event treatment is called for which a physician or other health care provider refuses to administer without my/our consent, I/we hereby authorize the staff of HBC or any other representative of HBC, to give such consent and further agree to hold any person harmless from any claims, demands, or suits of any nature arising from the giving of such consent so long as the treatment is administered by or under the supervision of a licensed physician. I further authorize the release of the listed medical information to appropriate medical personnel and/or the health coverage insurance company. I will notify my home church if I feel there are any health considerations that would prevent my child's participation in any activities that they have any questions about for health or other reasons.

The intention of this release is to grant authority and perform any and all examinations, treatments, anesthetics, operations and diagnostic procedures which may now or during the course of the patient's care, be deemed advisable or necessary by any qualified physician. I will see that payment is made for all medical expenses incurred from medical treatment for the named child. This payment will be made by me or by my insurance company providing coverage for the above-named child.

As a parent (or legal guardian), I the undersigned, certify that my child, named above, has my express permission to participate in all activities, of any nature, sponsored by HBC for the year. I fully release the HBC, its authorized representatives and staff, and it's participating churches from all liability of any kind and character upon any claim, demand, or cause of action that might be asserted in our behalf against said Association, church, representatives or staff.

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Child's Name *
Grade Completed *
City, State, & Zip Code *
Any health problems or medical difficulties which are being treated for? *
List of medicines or substances to which you are allergic to: *
Medications you are currently taking: *
List any previous operations or serious illnesses: *
List any special diet or special needs: *
Family Physician & Phone Number: *
Insurance Co., Policy Number, Subscriber Name, Subscriber Phone Number: *
Emergency Contact Name, Phone and Relationship to student: *
Parents Signature *
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