JYM 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*

Grade for 2020-21 School Year?

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, 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 Liability

I, 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?

The JYM Student Medical Release Form

Physician-Medical Insurance Information

Medical History-Immunizations

Allergies

Medical Release

Release of Liability