Bridges Community Church - Medical & Liabilities Release Form 2024
In order to keep our students happy and safe at a BCC event, we need some helpful information from you.  Please fill out the information below for our records.  Please complete ONE form for each student.  

IMPORTANT:  Forms will need to be updated yearly to ensure we have the most up-to-date information for each student.    

Questions?  Email Kathy Spillar at kathy@bridges.church 
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For what area of ministry are you completing this form?
Student's Full Name *
Date of Birth
MM
/
DD
/
YYYY
Grade
Parent / Guardian Name
Phone Number
Email Address
Parent / Guardian Name 2
Phone Number
Email Address
With Whom Does the Student Live?
Address Where Student Lives (e.g., 123 Main St., Los Altos, CA 94024)
Emergency Contact Name (Other than Parent / Guardian listed above)
Phone Number
Emergency Contact - Relationship to Student
Name of Healthcare Provider and/or Preferred Hospital *
Physician Name *
Health History
Name & dosage of any medication student takes on a regular basis
Other Medical Notes
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