Whitney Free Will Baptist

847 Iron Ore Rd Spartanburg South Carolina

Youth Ministry Program

MEDICAL AUTHORIZATION FORM AND PARENTAL PERMISSION FORM

TIME: _______________

Event Name:________________________________________   

 

Place: _________________________________________          

 

Date(s):_________________________

 
 
Trip Details: We are leaving by rental van, Car, Church Van, Bus on    ______________________  .
from the church parking lot and return back at church at around ______________________.  PLEASE HAVE YOUR PERMISSION SLIP FILLED OUT AND RETURNED TO THE CHURCH BY _______________________________.
 

Participant Name:                                                                   Birth date: ____________

 

I give permission for my child to attend the Whitney Free Will Baptist Church ( WFWBC) event listed above.

Medical Release to Grant Consent

I hereby request and authorize the WFWBC youth groups leaders and/agents, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child.  This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.
_________________________                            _____________________________                        ____
Signature of ParenT                             Printed name of Parent                       Date
or Legal Guardian                                                or Guardian                   

 

Activity Release

I further give permission for my child to participate in all supervised activities except as noted:

______________________________________________________________________________________
______________________________________________________________________________________
 
 
_________________________                            _____________________________                        ____
Signature of ParenT                             Printed name of Parent                       Date
or Legal Guardian                                                or Guardian                   
 
Release of Activity Liability Statement  i hereby release Volunteers and WFWBC youth group and Whitney Free Will Baptist Church from the responsibility of  any liability involving injury or accident to my child participating in the activity listed above on the given date listed.  I as the parent or guardian of the participant listed above,   I herby release WFWB Church and Volunteers from the accident or injury causing circumstances and will accept full responsibility for my child’s actions.  
_________________________                            _____________________________                        ____
Signature of ParenT                             Printed name of Parent                       Date
or Legal Guardian                                                or Guardian                   

 

EMERGENCY CONTACT INFORMATION

Parent/Guardian   Phone Numbers Phone Type     (Home, Mobile, etc.)
       
Name(s)      
       
Street Address      
           
City State Zip   Phone Numbers Phone Type     (Home, Mobile, etc.)
Other Emergency Contact    
         
         
Name(s) Relationship to Participant      

 

HEALTH CARE INFORMATION

 

Participant Name: ___________________________________________

 

Physician   Dentist
     
Name   Name
     
Phone   Phone
     
Medical Insurance Company   Dental Insurance Company
     
Policy/Group Number   Policy/Group Number
     
Name of Policy Holder   Name of Policy Holder

Facts concerning the child’s medical history including: allergies, medications being taken, and any physical impairments to which a physician should be alerted: