First Baptist Church of Fergus Falls

Children’s and Youth Ministry

Medical Release Form

September 2007 – August 2008

Because of the increasing sophistication of our hospital systems, we have found it necessary to have a signed parental release form in the unlikely event of some serious injury requiring hospital treatment.  This release gives us permission to take your child to the nearest available medical facility and have the necessary medical treatment administered.  This is not necessary from our perspective, but from your perspective, since many hospitals will not administer any medical attention to a minor without some parental consent.

Please read and sign the statement below.  This provides permission to seek whatever medical attention may be necessary.  It also releases First Baptist Church of Fergus Falls and/or the church’s personnel from any liability against personal injury or loss.

We understand the arrangement and believe that the necessary precautions and plans for the care and supervision of the child will be taken during their participation in First Baptist Church programs and/or trips.  Beyond this, we will not hold responsible First Baptist Church of Fergus Falls or the person supervising the program and/or trip.

In case of emergency, I understand that every effort will be made to contact me.  If I cannot be reached, I hereby give the Children’s and/or Youth leadership, staff, or other emergency medical personnel the permission to act on my behalf in seeking emergency medical treatment for this child in the event that such treatment is deemed necessary by the First Baptist Church volunteer / leadership or church staff.  I give permission to those administering emergency medical treatment to do so using those measures deemed necessary.  I absolve First Baptist Church of Fergus Falls, and/or church personnel from Liability in acting on my behalf in this regard so long as they are not grossly negligent.

Name of Child:_________________________________________________________________

 

Signature of Parent/Guardian:____________________________________________________

                                                            (Mother)                                  (Father)

Work Phone:___________________ Home Phone:_____________ Date Signed:___________

Insurance Company_______________________  Policy Number:________________________

If Parent/Guardian are not available, please call person below:

Name:_____________________ Phone #1:_________________  Phone #2:____­­­­­___________

Relationship to Student:_________________________________________________________

Additional comments regarding medical history, allergies, penicillin, drug reactions, etc., which may be needed in treatment.