2011-2012 Medical Release Form
Highland Avenue Baptist Church
-For all activities sponsored by Highland Avenue Baptist Church between August 14, 2011 through August 12, 2012-
I. General Information (please print clearly)
Name of Participant: _______________________________________________
Address: _________________________________________________________Phone Number: ____________
City: _____________________________ State:_______________________ Zip:______________________
Birth Date (m/d/y):__________________ Grade (’11-‘12):_____________________________________
Gender: male female
Mother’s Name: ___________________________________________________
Mother’s Contact Info: Daytime Phone Number__________________________
Evening Phone Number___________________________
Cell / Pager Number_____________________________
Father’s Name: ___________________________________________________
Father’s Contact Info: Daytime Phone Number__________________________
Evening Phone Number___________________________
Cell / Pager Number______________________________
Alternate Contact Name: ______________________________________________
Alternate Contact Info: Daytime Phone Number__________________________
Evening Phone Number___________________________
Cell / Pager Number______________________________
II. Medical Information
Primary Health Insurance Company_____________________________________________________________
Name of Policy Holder: ______________________________________________________________________
Policy Number_________________________________ Group Number________________________________
Doctor’s Name_________________________________ Phone Number_______________________________
Hospital Preference_____________________________ Date of Last Tetanus Shot (m/d/y) _______________
Secondary Health Insurance Company_________________________________________________________
Name of Policy Holder: ____________________________________________________________________
Policy Number_________________________________ Group Number____________________________
-over-
Medical Information - Continued
Please list special medical issues (diabetes, medication allergies, rare blood type, high blood pressure, etc.)
__________________________________________________________________________________________
Please list any physical limitations that might hinder participation in activities (allergies, asthma, etc.)
__________________________________________________________________________________________
Please list any medications (and doses) that are taken regularly:
__________________________________________________________________________________________
III. Release Form
1. For Minor Child
I hereby certify that I am the parent or legal guardian of the named participant and I give my
permission for him/her to take part in any of the activities sponsored by the Highland Avenue Baptist Church
(HABC). I am aware that there might be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless HABC, its officers and directors, employees, and any parties volunteering on behalf of HABC, from all actions, costs, expenses or damages of any kind growing out of or related to any activities or transportation to and from the activities.
In case of medical emergency, I hereby authorize the treatment of the named participant by a qualified and licensed medical physician if in the opinion of the physician the situation may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authorization is granted only after a reasonable attempt has been made to contact me.
Signature of Parent or Guardian: ______________________________________Date:__________________
2. Adult Student (over 18) or Leader
I hereby certify that to the best of my knowledge I am in a state of health sufficient for me to take part in any of the activities sponsored by HABC without jeopardizing my well being. I am aware that there might be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless HABC, its officers and directors, employees, and any parties volunteering on behalf of HABC, from all actions, costs, expenses or damages of any kind growing out of or related to any activities or transportation to and from the activities.
Signature of Parent or Guardian: ______________________________________Date:__________________
