Adult Medical Release Form Adult Medical Release Form Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone:Cell Phone:Work Phone:Email: Date of Birth* Date Format: MM slash DD slash YYYY Physician-Medical Insurance InformationPhysician:Business Number:Insurance Company:Policy Number:Medical History-ImmunizationsDo you have any special health information that First Baptist Church Joelton should be aware of?* Yes No If so, explain:Tetanus ImmunizationPolio Booster ImmunizationMeasles/Mumps ImmunizationCheck Box Below To Give Appropriate Information: Asthma Sinusitis Bronchitis Kidney Trouble Diabetes Heart Trouble Dizziness Stomach Upset Hay Fever Other List Other:AllergiesFood:Penicillin or Other Drug Name:Insect Sting/Bites:Poison Sumac, Oak, Ivy:Medical ReleaseI give the sponsors of First Baptist Church Joelton the authority to provide or sign for medical treatment for myself in case of emergency.* Yes No Release of LiabilityI do not hold First Baptist Church Joelton liable for any injuries, accidents, or illnesses incurred during participation in this ministry. I understand that I am responsible for the expenses of my medical care and that my insurance is primary.* Yes No Parent or Legal Guardian's Name* First Last Parent or Legal Guardian's Phone*Questions or Comments?