Student Ministry Medical & Liability Form

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  • I. Personal Information

  • Date Format: MM slash DD slash YYYY
  • use all zeros if this does not apply, but you must have at least one phone number filled in
  • use all zeros if this does not apply, but you must have at least one phone number filled in
  • use all zeros if this does not apply, but you must have at least one phone number filled in
  • Emergency Contact Information

  • II. Medical Information

  • III. Medical Insurance Information

    (Please provide copy of insurance cards)
  • Drop files here or
  • IV. Permission to Receive Medical Attention

  • I give permission for my child to receive medication and emergency treatment in the event of illness or accident. I give the person(s) designated by South River Baptist Church to be counselor/chaperone for this event permission to make a decision concerning emergency treatment.
  • V. Discipline

  • I would like to inform the leaders of this event that I fully trust their judgments and decisions toward the well being of my child. I trust my son/daughter to adhere and abide by any and all rules set forth and decisions made by the counselors. If my child does not, I expect them to be disciplined without the use of physical force as deemed necessary by the person(s) designated by South River Baptist Church to be counselor/chaperone for this event.
  • VI. Liability Release

  • I hereby release South River Baptist Church , their staff, chaperones and counselors of any and all liability in the event that my child is injured or becomes ill while in their care.
  • Date Format: MM slash DD slash YYYY

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2659 S. Chipley Ford Rd.

Statesville, NC 28625

704-876-1520

southriverbaptist.com