Western Heights Baptist Church Medical Release Form 2019
Children's Ministry Medical Release form for Western Heights Baptist Church
This form is valid from January 1, 2019- December 31, 2019.
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Email *
Child's first and last name *
Male/female *
Child's date of birth *
MM
/
DD
/
YYYY
Child's age/grade *
Parent/guardian first and last name *
Address line 1 *
City *
State *
Zip code *
Best phone number *
Alternate phone number
If parent/guardian is not available in an emergency, notify *
Relationship of emergency contact to child *
Emergency contact phone number *
Additional emergency contact name
Relationship of additional emergency contact to child
Additional emergency contact phone number
Does this child have any of the following allergies? *
Required
Food allergies?  If so, what?
Any other allergies?  If so, what?
Does this child have any medical or health problems/conditions, and or has this child had any chronic or recurring illness or illnesses *
If yes, please describe the problems or illnesses
Child's family physician *
Physician's phone number *
Describe any dietary restrictions this child is required to follow
List any physical restrictions that would limit participation in any activities
Date of child's last tetanus shot
Is there medical or hospitalization insurance which provides benefits for this child? *
Name of insurance company
Phone number
Policy holder's full name
Policy number
Group number
In the event that medical care is required during the time period specified above, I (we) hereby grant permission for the appropriate staff member or adult sponsor of Western Heights Baptist Church, Waco, Texas, to secure medical care for my (our) child, and I (we) hereby grant the physician(s) permission to provide any and all medical care necessary (including examination, diagnosis, anesthesia, medical , hospital, and surgical procedures or treatments) for my child's well-being.  I (We), the undersigned parent(s) and/or guardian(s) of the above child, do hereby release, acquit, discharge, and hold harmless Western Heights Baptist Church and its representatives, from any and all damages and liabilities arising out of the medical care provided to my (our) child under this Medical Authorization.  I (We) understand the Western Heights Baptist Church and its representatives shall incur no liability whatsoever while attending to the medical needs of my (our) child and for obtaining medical care for my (our) child as they deem appropriate.  If only one parent or guardian signs this instrument such individual hereby represents that he or she has obtained the other parent's or guardian's agreement to the terms of this instrument.
Parent/Guardian signature *
Parent/Guardian signature
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