Medical Release/Parental Consent Form

Dahlonega Baptist Church

Children, Students and At-Risk Adults
2012 - 2013

Name of Child/Student: ______________________________________ Date of Birth: __________________

Gender: ______________ Grade: ____________School:_________________________________________
Address: _______________________________________________________________________________
Street
City
State
Zip
Home Phone: __________________________________ Child/Student Cell Phone: ____________________
Home E-mail: __________________________________ Child/Student E-mail: ________________________
Name of Father/Guardian _______________________ Work Phone: ___________ Cell Phone: __________
Father E-mail _________________________ Father Place of Employment: __________________________
Name of Mother/Guardian _______________________Work Phone: ___________ Cell Phone: __________
Mother E-mail _______________________ Mother Place of Employment: ___________________________
Child/Student lives with: Both Parents ______ Mother ______ Father ______ Other_____________________
Member of Dahlonega Baptist Church? ______ Guest of _________________________________________
In event of illness or emergency and parents cannot be reached, we should notify:
Name______________________________ Relationship__________________ Phone: _________________
Name______________________________ Relationship__________________ Phone: _________________
Physicians Name _______________________ Phone: ______________ Hospital Preference____________
Insurance Company___________________________________ Policy #_____________________________
MEDICAL HISTORY: Check the ones that apply to your child/student:
_____Asthma _____Fainting Spells

_____Heart Condition _____ Diabetes _____Headaches

_____Sinus trouble _____Epi-Pen _____Hearing problems _____Seizures ____Other:_________________

Does your child/student wear contact lens? _____ Glasses? _____ Date of last Tetanus Shot: ____________
Special Health Needs:
_______________________________________________________________________________________
Is your child/student currently under a Physicians care for any illness (if yes, please explain)?
_______________________________________________________________________________________
_______________________________________________________________________________________
Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
ALLERGIES: List allergies (food and drug) your child/student has:
Medication that may cause an allergic reaction: _________________________________________________
Food: ______________________________________ Treatment: __________________________________
Penicillin or other drugs: _______________________ Treatment: __________________________________
Insect bites/stings: ____________________________ Treatment: __________________________________
Poison Sumac, Oak, Ivy: _______________________ Treatment: __________________________________
Other: ______________________________________ Treatment: __________________________________
Other: ______________________________________ Treatment: __________________________________
(Please continue on back)

MEDICATIONS: (Include prescription, over-the-counter, and herbal medication.)

Name
Used to treat
1) ____________________________________ __________________________________________
2) ____________________________________ __________________________________________
3) ____________________________________ _________________________________________

Release, Discharge, Waiver and Hold Harmless Agreement

I, ______________________________________, Parent/Guardian of ______________________________,
a minor presently under my care, custody, and control, has my permission to attend and participate in
activities sponsored by Dahlonega Baptist Church from August 1, 2012 through July 31, 2013.
I understand that the risk of injury from any recreational and work activity is significant, including, but not
limited to, the potential for permanent paralysis and death. While particular rules, equipment, and personal
discipline may reduce this risk, the risk of serious injury does exist. I knowingly and freely assume all risks,
both known and unknown, even if arising from negligence, and assume full responsibility for my
childs/students participation and observing of such recreational and work activities.
I do hereby release, forever discharge, and covenant to hold harmless Dahlonega Baptist Church, its staff,
employees, and sponsors from any and all liability, claims or demands for personal injury, sickness and
death, as well as property damage and expenses, of any nature whatsoever while participating in any event
sponsored by Dahlonega Baptist Church, including travel to and from any church activities. This agreement
also applies to any and all activities on or off church property.
I hereby authorize any staff member and/or adult sponsor who may be supervising or directing any activity
sponsored by Dahlonega Baptist Church, to authorize medical treatment, including but not limited to
emergency surgery. I agree to assume liability for any and all costs and expenses incurred, including medical
and dental costs, and that Dahlonega Baptist Church, its staff, employees, and sponsors with them are not
responsible.
Parent(s) or persons who are designated as emergency contacts (as listed on the front of this form) will be
notified if my child/student becomes ill or injured. I agree to come in person or to direct the emergency contact
to collect my student upon notification. Further, if any staff, employee, or sponsor deems it necessary for my
child/student to return from any trip due to illness, injury, or misconduct, I agree that he/she will be sent home
at my expense and without a refund.
I assume full responsibility for any damage to property and/or equipment caused by my child/student and I
understand I will be responsible for replacement of same.
I give my permission for my child/student to ride in the church vehicle(s) and any vehicle designated by the
adult in whose care the minor has been entrusted while attending and participating in activities sponsored by
Dahlonega Baptist Church.
Photos or videos taken of my child/student during any event may be used to promote and/or report on the
event in any Dahlonega Baptist Church advertising, publication or media, including website. Names of minors
will not be used.
I give authority and permission to Dahlonega Baptist Church, its staff, employees, and sponsors to inspect my
childs/students belongings.
I understand that Dahlonega Baptist Church sponsored activities provides a place where children/students
can seek counsel and advice from adult leaders, staff, counselors, and others. I hereby consent to my
child/student receiving spiritual and emotional counsel.
This authorization covers the period from August 1, 2012 through July 31, 2013, inclusive.

_____________________________________________________________ ___________________
Parent/Guardian Signature (Must sign in the presence of a Notary Public)
Todays Date
______________________________________________________ __________________________
Notary Public Witness
Todays Date
My commission Expires ____________________________________