Crosswell First Baptist Church Medical Release Form
Information and Medical Release Form. If you are completing this form for yourself as an adult and come to a selection that doesn't apply and is required, type none or N/A
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Email *
Participant's Name *
Address: *
Birthday: *
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/
DD
/
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Current Grade   *
Email Address:
Home Phone:
Cell Phone: *
Mother/Guardian Name: *
Father/Guardian Name: *
Mother/Guardian Phone Number: *
Father/Guardian Phone Number: *
Emergency Contact Name/Number: *
Emergency Contact Name/Number *
Other Family Members Attending Crosswell First *
Anything you would like to share about your student (medical, learning needs, hobbies, etc.) *
Preferred Physician's Name/ Phone Number *
Preferred Dentist's Name/Phone Number: *
Name of Insured & Policy # *
Medical Insurance Company Name: *
List any medications participant takes regularly:
Medical Emergency Consent Form:
In the event the above listed student has need of medical attention, I do hereby give my permission for the staff and volunteers of Crosswell First Baptist Church to seek such help including emergency surgery if the particular medical emergency warrants. I understand every effort will be made to contact me or my alternate responsible party prior to emergency procedures, unless the situation does not allow due to threat of loss of life. I give my minor child full consent to attend the activities of Crosswell First Baptist Church. It is my understanding that the staff and volunteers will take ALL necessary precautions to ensure the safety of my child. I do hereby release Crosswell First Baptist Church from any legal or financial obligation due to the injury of my above named student.
Transportation Allowance: My above listed student is allowed to travel with Crosswell First Baptist Church in the transportation provided by the above listed church.
Clear selection
I give Crosswell First Baptist Church, permission to photograph/video my student and use his or her pictures in the church digital and print communications. *
Typed Signature: *
This Form Is In Effect From January 1st, 2022-December 31st, 2022
A copy of your responses will be emailed to the address you provided.
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