8/6/2019 Medical Release Form City Museum

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PLEASE ATTACH A COPY OF YOUR MEDICAL INSURANCE CARD TO THIS FORM

INDIVIDUAL REGISTRATION / MEDICAL RELEASE FORMCity Museum 2011

EVERY youth AND adult attending the event must have one of these forms completed and signed. Church group leader shouhave access to all forms for group during the weekend in case of emergency. Review the information in the behavior statemewith your youth. Please type or print legibly. Youth under the age of 18 must also have permission portion at the bottom signeDATE OF EVENT: ______- _______- _______ NAME OF EVENT: City Museum 2011

Month Day(s) Year

Check/complete appropriate boxes: Male ___ or Female __ Adult_____ or Youth ____Age _____ Grade ____

NAME:____________________________ _____________________________ HOME PHONE:(_____) _____-___________Name you go by Last name

ADDRESS:__________________________________________________________________________________________Mailing Address City State ZIP

MEDICAL INSURANCE CO.:____ ____________________________________ POLICY NO.: ________________________

NAME OF PERSON ON POLICY:____________________________________ RELATIONSHIP _______________________

EMERGENCY CONTACT: __________________________________________RELATIONSHIP:_______________________

EMERGENCY PHONE # (_____)______ -__________ ALTERNATE EMERGENCY #: (______)______-_____________

KNOWN ALLERGIES?_________________________________ LIMITATIONS?____________________________________

PLEASE LIST ALL MEDICATIONS CURRENTLY USING OR MAY TAKE: _________________________________________

NAME OF CHURCH: _______________________________________ PASTOR'S NAME: ___________________________* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

PERMISSION FOR MINORS: I hereby give permission for my child __________________________ to attethe above named youth event and participate fully in activities. I understand that my child will be at the CityMuseum on June 8, 2011, of this trip. I understand that there are risks associated with this activity and will nohold the church responsible for injuries sustained on said trip. I also agree to not hold responsible those in

leadership for the risk of injury. I also understand that the leadership will do everything possible to prevent suan event happening.

EMERGENCY MEDICAL CARE: In the event that _____________________________________ (personattending event) suffers any illness or accident requiring emergency hospitalization while at this First BaptistChurch of Dexter event, I hereby give permission for any necessary hospitalization. I hereby give permissionthe physician selected to order x-rays, routine tests, and treatment for the health of the above named. I realizthat every effort will be made to contact me and/or the contact person above in case of emergency. In the evethat I may not be able to be reached in an emergency, I hereby give permission to a physician to hospitalize /secure proper treatment for / order injection or anesthesia for the above named. I will not hold the First BaptisChurch Dexter responsible in the event of accident, loss, or death.

__________________________________________________ ______________________________________________If this form is for adult participant at the event, please sign here. If this form is for youth under age 18, parent/guardian must sign he