JYM Medical Release Form The JYM Student 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* Grade for 2017-18 School Year?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, as parent/guardian, give the adult sponsors of the First Baptist Church Joelton the authority to provide or sign for medical treatment for the student listed above.* Yes No Release of LiabilityI, as parent/guardian, give permission for the above listed student to attend all FBC Joelton youth events for the current school year including social outings after church on Sundays and Wednesdays. I 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 child's medical care and that my family insurance is primary.* Yes No Parent or Legal Guardian's Name* First Last Parent or Legal Guardian's Phone*Questions or Comments?