Medical

Release
Form
 I,________________(Parent/Guardian) hereby give Reedy Fork Baptist Church and /or its representatives permission to
secure medical treatment for ____________________(my child) while he/she is in his care. I also understand that I will be contacted
regarding any major conditions.

Signature of Parent/Guardian______________________________________________________________Date____/____/_______

Home Address:______________________________________________________________________________________________

Home Phone Number:___________________________

In Case of Emergency, Notify(if Parent/Guardian can’t be reached)

Name:_________________ Phone #_________ Relationship:______________

Teen’s Social Security Number: ___________________________________

Name & Phone number of Family Doctor:___________________________

Name & Phone number of Family Dentist:___________________________

Insurance Name and Policy Number:_______________________________

Medication that student takes on regular basis: _____________________________________________

Students known Allergies: _____________________________________________________________

Students known medical conditions/diseases: ______________________________________________

__________________________________________________________________________________

Does student have any history of asthma, seizures, hyperactivity, attention deficit disorder, frequent headaches, or stomach aches? If so
Please explain._________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Is there any other special medical related information that I should know?

Please explain._________________________________________________________________________________________________

_____________________________________________________________________________________________________________

(This form must be completed and turned in on day of departure)