Eastport Baptist Church
Medical & Activity Release Form
Dates:April 5 -6, 2010 Quarantine
General Information
Name of Participant:_______________________________ Date of Birth:_____________
Address:__________________________________________________________________
Person to contact in case of emergency: __________________________________
Phone:_________________________ Cell Phone _________________________________
Alternate Contact Person:_____________________________ Phone:__________________
Medical Information
If your child should require medical attention for injuries received or illnesses contracted prior to activity, please
send us the necessary information to give him/her proper medical care during his/her time with the youth ministry
activity. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury
while your child is at the activity.
Name of insurance company______________________________________________________________
Policy# ________________________ Group# _______________________
In whose name is the insurance? __________________________________________________________
Family Doctor ______________________________ Phone # ____________________
Dentist ___________________________________ Phone # ____________________
Health History
Any pre-existing or present medical conditions: ______________________________________________
____________________________________________________________________________________
Name and dosage of any medications that must be taken _______________________________________
____________________________________________________________________________________
List Allergies: _________________________________________________________________________
Any major illnesses during this past year? ___________________________________________________
Date of last Tetanus shot: ____________________ Contact lenses Yes / No
Any activity restrictions? Yes / No If yes, what: ___________________________________________
Release and Waiver
I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the
persons listed on this form. In the event I cannot be reached in emergency during the activity dates shown on this
form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure
medical treatment and/or order injection, anesthesia, or surgery for my child as deemed necessary.
I understand all reasonable safety precautions will be taken at all times by the Eastport Baptist Church and its
agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent
possibility of risk. I agree not to hold Eastport Baptist Church, its leaders, employees, and volunteer staff liable for
damages, losses, diseases, or injuries incurred by the subject of this form.
Signature of parent/guardian:__________________________________________ Date: ______________
Event: