Student Ministry Medical & Liability Form - South River Baptist Church

I. Personal Information
Child's Name*
First Last
Birthdate*
Month
Day
Year
Age*
Grade*
(M)ale/(F)emale*
Address*
Street Address City State ZIP Code
Parent or Guardian's Name*
First Last
Home #*
use all zeros if this does not apply, but you must have at least one phone number filled in
Work #*
use all zeros if this does not apply, but you must have at least one phone number filled in
Cell #*
use all zeros if this does not apply, but you must have at least one phone number filled in
Email*
Enter Email Confirm Email
Emergency Contact Information
Emergency Contact Name*
First Last
Relationship*
Phone #*
Who may pick up your child at the end of the camp other than the Parent or Guardian (list all names of those eligible)
II. Medical Information
Please list any medical or other information we need to know (include any and all allergies, food allergies, medications or other special needs)
III. Medical Insurance Information
(Please provide copy of insurance cards)
Insurance Carrier*
Policy Number*
Name of Policy Holder*
First Last
Copies of Insurance Cards
Drop files here or

Max. file size: 512 MB.
IV. Permission to Receive Medical Attention
Name of Person Giving Permission for 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.
First Last
V. Discipline
Name of Person Giving Permission for 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.
First Last
VI. Liability Release
Name of Person Giving 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.
First Last
Parent/Legal Guardian Signature (typed name)*
Date*
MM slash DD slash YYYY

2659 S. Chipley Ford Rd.

Statesville, NC 28625

704-876-1520

southriverbaptist.com

I. Personal Information

Emergency Contact Information

II. Medical Information

III. Medical Insurance Information

IV. Permission to Receive Medical Attention

V. Discipline

VI. Liability Release

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