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* Date Format: MM slash DD slash YYYY Grade for 2019-20 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, Wednesdays and through the summer. 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?