Parkhills Baptist Church- Annual Medical Release/permission
Name of Parent/Guardian:
(Required)
First Name
Last Name
How old are your children?
Kids
Students
Both
Kids (birth-5th Grade) Students (6th-12th grade)
Parent E-mail
(Required)
Home Address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent Phone #:
(Required)
Parent Phone #:
Child #1 Info
(Required)
First
Last
Child #1 Date of Birth
(Required)
MM slash DD slash YYYY
Child #1 T- Shirt Size
Kids Small
Kids Medium
Kids Large
Small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Date of last Tetanus (If known) Child #1:
MM slash DD slash YYYY
Child #2 Info
First
Last
Child #2 Date of Birth
MM slash DD slash YYYY
Child #2 T- Shirt Size
Kids Small
Kids Medium
Kids Large
x-small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Date of last Tetanus (If known) Child #2:
MM slash DD slash YYYY
Child #3 Info
First
Last
Child #3 Date of Birth
MM slash DD slash YYYY
Child #3 T- Shirt Size
Kids Small
Kids Medium
Kids Large
x-small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Date of last Tetanus (If known) Child #3:
MM slash DD slash YYYY
Child #4 Info
First
Last
Child #4 Date of Birth
MM slash DD slash YYYY
Child #4 T- Shirt Size
Kids Small
Kids Medium
Kids Large
x-small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Date of last Tetanus (If known) Child #4:
MM slash DD slash YYYY
Child #5 Info
First
Last
Child #5 Date of Birth
MM slash DD slash YYYY
Child #5 T- Shirt Size
Kids Small
Kids Medium
Kids Large
x-small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Date of last Tetanus (If known) Child #5:
MM slash DD slash YYYY
Medical/Emergency Contacts
In the event of an emergency, give the name and phone number of friends or relatives we can contact who will know how to reach parents or guardians.
Doctor's Name:
First Name
Last Name
Insurance Company:
Policy #:
Emergency Contact #1:
(Required)
First Name
Last Name
Relationship #1:
(Required)
Emergency Phone #1:
(Required)
Emergency Contact #2:
(Required)
First Name
Last Name
Relationship #2:
(Required)
Emergency Phone #2:
(Required)
List any food/drug allergies & medical conditions. Please list Childs name, followed by the content example: "BOB: Allergic to peanuts."
(Required)
Type N/A if not applicable
List of Medications taken regularly. Please list Childs name followed by the content example: "BOB: Advil at 8am."
(Required)
Write the name of medication/amount/when it is taken (Type N/A off not applicable)
Any other instructions regarding minor. Please list Childs name followed by the content example: "BOB: loves to have fun, but needs time to relax".
(Required)
(Type N/A if not Applicable)
Photo Release
By Checking yes in the box below, I give Parkhills Baptist Church the permission to photograph my child and use his or her picture solely for the church’s website or Social media (facebook/instagram) page.Parkhills Baptist Church will never publish a child’s name with any of its publications.
(Required)
YES
NO
Authorization To Consent To Treatment:
I/we, the parent/guardian, of the above-named minor/participant, to take part in various trips, outings, and camps of Parkhills Baptist Church- San Antonio, Texas. i also give my permission for my teenager to be transported in vehicles used in conjunction with these events. I further give my permission for the designated/approved church representative or sponsor to secure any needed medical treatment for the above named son/daughter. I release the church representatives/sponsors from liability for accident or injuries on these trips or activities. I further understand and agree that, in the event that the above named son/daughter be involved in any non-Christian or dangerous activities, I will pay his/her expense to be sent home immediately at the discresion of approved sponsors/and or church representatives.
I have supplied ,understood, and agree to all the information contained on this Medical Release/permission form.
Please Select:
(Required)
I, (The Parent/Legal Guardian) Give Consent
I, (The Parent/Legal Guardian) Do Not Give Consent
Parent/Guardian Signature:
(Required)
Date
(Required)
MM slash DD slash YYYY
Post Image
Accepted file types: jpg, jpeg, png, gif.
