Children Medical Permission Form

Child's Information

Child's Name

Date of Birth

Address

Phone

Child's Medical Information

List any medical conditions for which your child is currently being treated.

Known Allergies:

Medications your child is currently taking:

Child's Insurance Information

Insurance Company

Policy Number

Subscriber Name

Subscriber Number

Parent/Guardian Information

Parent/Guardian's Name

Phone

This address will receive a confirmation email

Emergency Contact Information (Other than Parent/Guardian)

Emergency Contact Name

Phone

Relationship to Child

Permission for Medical Treatment

I give my permission for Saltillo First Baptist Church Children's Director, church official, or adult present or in charge of First Aid, to obtain necessary medical attention in case of sickness or injury to my child. I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge Saltillo First Baptist Church, the Children's Director, or Pastor from any and all claims, demands, actions, or causes of action, past, present, or future arising out of any damage or injury while participating in this event. I agree to indemnify Saltillo First Baptist Church for any and all claims, demands, damages, injuries, costs, suits or causes of action, past, present, or future, arising out of or caused by my child while participating in this event. Complete and sign below (youth under 18 years of age requires Parent/Legal Guardian signature).

Parent/Guardian Signature

Description

Please fill out this Medical Permission form and click submit.

Children Medical Permission Form

Description

Please Fix the Following