Form: Adult Medical Release

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*

Physician-Medical Insurance Information

Physician:

Business Number:

Insurance Company:

Policy Number:

Medical History-Immunizations

Do you have any special health information that First Baptist Church Joelton should be aware of?*

Yes
No

If so, explain:

Tetanus Immunization

Polio Booster Immunization

Measles/Mumps Immunization

Check Box Below To Give Appropriate Information:

List Other:

Allergies

Food:

Penicillin or Other Drug Name:

Insect Sting/Bites:

Poison Sumac, Oak, Ivy:

Medical Release

I 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 Liability

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 medical care and that my insurance is primary.*

Yes
No

Adult's Name*

First Last

Phone Number*

Questions or Comments?

Adult Medical Release Form

Physician-Medical Insurance Information

Medical History-Immunizations

Allergies

Medical Release

Release of Liability