Activity Permission Form

MEDICAL FORM

To be used by all ministries that need relese forms

Please fill out form below and turn into the Group Leader

STUDENT NAME AGE

ADDRESS:

City: State: Zipcode:

PARENT(s) NAME(s)

Home Phone: Work Phone:

Cell Phone:

Are you presently taking any medication for any sickness or allergy?(check if yes)

If “yes”, what?

Are you allergic to any medication?(check if yes)

If “yes”, what?

Is there any other information concerning your health that the adults need to be aware of?

Is it ok to give your child tylenol?(check if yes)

PARENTS STATEMENT

In allowing my child(ren), _________________________________________________

to go to , I give my consent to the chaperones to act as guardians on my behalf. In the event of a medical emergency of any kind, I expect the chaperones to make mature decisions that affect the safety of my child. I will not hold the chaperones or Salem Baptist Church personally responsible for any injury my child incurs while on this trip.

I consent to the use of photographs taken of my child for purpose of promoting Salem Baptist Church, its programs and events in print, video, and on the internet.

Yes No

Parents Signature_________________________________________Date_______________

Insurance Company and Number________________________________________