General Permission and Medical Release Form
Cordova First Baptist Church
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Event Name *
Date of Event *
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Child/Participant Name *
Child/Participant Age *
Child/Participant Birthday *
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Child/ Participant Address *
Guardian Name *
Primary Phone Number *
Secondary Phone Number
Special Dietary Restrictions:
Allergies:
Medications:
If medications are needed, may the child self administer the medication?
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Does the participant have any chronic or reoccurring illnesses? If so, please elaborate:
Has the participant had surgery or a serious illness in the past year? If so, please elaborate:
Identify any other limits, restrictions, or disabilities that could prevent the participant from fully participating in the event or activity:
Identify any other needs or considerations the participant has that the event or activity planner should be aware of:
I authorize Cordova First Baptist Church to provide supervision to my child. I understand that my son or daughter will NOT be allowed to leave unless escorted by a parent or legal guardian. It is understood that all possible caution will be taken by those persons in charge to prevent injuries, but neither the chaperones nor the church will be held responsible in case of an accident. I hereby authorize any adult representative of Cordova First Baptist Church to consent to any medical treatment of the above-named child, which in the judgment of a recognized medical facility, under the general or special supervision of a licensed physician, may be deemed necessary. I also understand that if the behavior of my child causes any disruption in the planned activity, I will be called at once to come and pick up my child immediately. *
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