Wildwood Youth Medical Release Form
Child information:
Name ________________________________
Age _______ Emergency Phone ____________
Address _______________________________ City ______________ St _____ ZIP ________
Family Insurance Co. ________________________________ Policy # ____________________
Allergies:
Penicillin or other drug (name)_________________________________
Any current medications you are taking (list) _________________________________________
My
permission is granted for the minister or sponsor in charge to transport my child
and/or to obtain
necessary medical attention in case of sickness or injury
to my child.
I, the undersigned, do hereby verify that the above
information is correct and I do hereby release and
forever discharge all
sponsors and employees of Wildwood Baptist church from any and all claims,
demands, actions or cause of action, past, present, or future arising out of any
damage or injury while participating in the youth event held at _________________________, on
(date, including year)
_______________________.
Signature
_______________________________________________ Date:__________
Parent/Gaurdian
Signature