EmailMe Form - BHBC Medical Release Form

BHBC Medical Release Form

I, the undersigned, am the parent and/or legal guardian for the child indicated below, who has my permission to attend youth activities sponsored by Bacon Heights Baptist Church and its Student Ministry, Sunday School Classes, and auxiliaries.
I hearby release Bacon Heights Baptist Church, its pastor, its staff, its members, any lending vehicles, and all volunteers from any and all liability by reason of accident or injury suffered by my student while participating in the various activities.
I authorize the placement of this form in the files of Bacon Heights Baptist Church.

Student Name *
First Last
Parent/Legal Guardian Signature *
Clear
Parent or Legal Guardian *
First Last
Date of Signature *
MM / DD / YYYY
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Parent/Legal Guardian Phone *
### - ### - ####
INSURANCE CARRIER *
POLICY NUMBER *
Isurance Carrier Phone *
### - ### - ####
Insurance Carrier Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region