Medical Release Form Name* First Middle Last Gender* Male Female Date of Birth* MM slash DD slash YYYY Age*<1123456789101112131415161718Grade*Pre-KK1st2nd3rd4th5th6th7th8th9th10th11th12thAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parents/Guardians NamesParent/Guardian Name 1* First Last Email* Cell Phone*Home PhoneParent/Guardian Name 2 First Last Email 2 Cell Phone 2Home Phone 2Medical InformationInsurance Company* Name of Primary Contract Holder* Policy Number* Group Number* Physician's Name* First Last Physician's Phone Number*Food Allergies* Allergies to Medications* List medications taken on a regular basis* List any fears, anxieties, or medical conditions that would need to be made known to assist him/her* Alternate Emergency Contacts:*NamePhone Number Guideline Agreement* By checking this box and typing your name, you are agreeing to the following:I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized or attended by Wall Highway Baptist Church. I/We understand that there are inherent risks involved in any ministry, event, or sports related activities, and I/We hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/We consent to any reasonable medical treatment as deemed necessary by a licensed physician. Wall Highway Baptist Church has my/our consent and permission to seek whatever means (medical or other) necessary to deal with the situation. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/We agree to hold such person(s) free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above during the stated dates. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the ministries staff member. I/We also agree and understand that WHBC may photograph or video your child/student for the purpose of crafts, church website, promotion, or presentations. A copy of your insurance cards may be requested by the ministry leader as needed. I am aware that the current form is effective for multiple years, with the exception of the Kid’s Ministry, Birth – 5th Grade, to be updated yearly. If the information above changes prior to 12/31/2024 it is my responsibility to change this form on file.Parent Name/Signature* CAPTCHA
