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Microsoft word - 2007-2008 permission-medical form.docm
Hayes Barton Baptist Church
Medical Release and Permission Form
Valid August 1, 2007 – August 31, 2008
Child's Name ______________________________________________________________________________ _____M _____F
Last First Middle
Birth date _____/_____/_____ Age _________ Grade ________ School
Address _______________________________________________ City ________________________ State ______ Zip
Phone ____________________________________________ Cell
Father’s Name ______________________________ Wk. #_______________________ Cell #
Mother’s Name _____________________________ Wk. #_______________________ Cell #
In case of emergency notify_________________________________________________ Phone #
Family Physician__________________________________________________________ Phone #
Family Insurance Co._________________________________________ Policy No.
[Note: Please attach a copy of your insurance card]
(Check ALL appropriate information)
_____Asthma _____Sinusitis _____Bronchitis _____Kidney Trouble _____Heart Trouble _____Diabetes _____Dizziness
_____Epilepsy/Seizure Disorder _____Upset Stomach ______Hay Fever ______ADD _____ADHD
Insect Sting/Bites (list): _________________________________ Poison Ivy, Oak, Sumac:
List any medications your child takes regularly:
Childhood Diseases: _____Chicken Pox _____Measles _____Mumps _____Whooping Cough
Does you child wear: _____Glasses _____Contact Lenses
Please rate your child’s swimming: _____good swimmer _____fair swimmer _____non-swimmer Should your child’s activities be restricted for any reason? Please explain:
We will have a first aid kit on trips that includes various over the counter medications. Please check off the medications listed that
you give your permission to be given by an adult to your child if necessary.
Tylenol ___ Ibuprofen ___ Benadryl ___ Dramamine ___ Hydrocortisone cream ___ Pepto-Bismol ___ Sunburn relief ___ Imodium
AD ___ Neosporin ___ Caladryl Lotion ____
This consent form gives permission to seek whatever medical attention is deemed necessary,
and releases Hayes Barton Baptist Church, Inc. and its staff of any liability against personal losses of named child.
I/We the undersigned have legal custody of the student named below, a minor, and have given our consent for him/her to attend events being
organized by Hayes Barton Baptist Church (“Church”). I/We understand that there are inherent risks involved in any ministry or athletic event, and
I/we hereby release the Church, its ministers, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to
person or property that may occur during the course of my/our child’s involvement
While I understand that the Church will take all reasonable steps to provide individual care and safety for my child, I am aware that the Church or their employees or agents cannot assume any responsibility for an injury, damage or harm which might result during the course of any activity during functions so sponsored. In consideration of permitting my child to participate, I agree that full responsibility will remain with me, as parent or guardian of my child. Should any claim be asserted by any person as the result of the acts of my child while participating in the course of activities provided by the Church, or traveling to or from such activity, or should my child assert any claim against the Church or its employees or agents, I agree to indemnify and hold the Church harmless from any such claim, including attorney fees and costs incurred by the Church in defense thereof.
In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named below. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Church staff member.
Activities may include, but are not limited to: Sunday School, choir, Bible studies, local mission projects, cookouts, boating, skiing, swimming, basketball, roller-skating, rollerblading, games in a park or other site, soccer, dodge ball, ice skating, volleyball, softball, baseball, camping, hiking, biking, concerts, golfing, miniature golf, hayrides, mission trips, retreats, parties. Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the Church prior to that event.
This document also gives my/our permission for my child to ride in private vehicles of adults supervising children and youth. ____________________________________________________________________ (Child’s Name) has my/our permission to travel and attend all activities sponsored by Hayes Barton Baptist Church from August 1, 2007 until August 31, 2008. Parent/Guardian Signature(s):
Code of Conduct
We expect all participants to conform to these general rules of conduct
No fighting, weapons, fireworks, lighters, or explosives
No possession or use of alcohol, drugs, or tobacco
No offensive or immodest clothing or language
No males in females’ sleeping quarters and no females in males’ sleeping quarters
No students can drive unless otherwise noted by Hayes Barton Baptist Church staff member
Respect of other participants, staff, and adult leaders
Follow the security procedures established for activities within the church building and at other locations
Adherence to curfews and travel locations
Other rules established by staff and adult leaders
The “laws of the land” will be respected and abided by at all times.
If a disciplinary situation occurs, parents will be contacted and will have to take their child home at the parents’ expense. I have read (or had read to me) the rules of conduct, the above medical information, and permission to participate in activities. I agree to abide by the stated personal limitations and the code of conduct. Child’s Signature:
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