Medical Release

Family Information & Release Form 2022

PARENT/GUARDIAN INFORMATION

* Indicates required field

Parent / Guardian Name(s) *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home or Cell Phone *

Work Phone *

Parent / Guardian Email *

CHILD INFORMATION

1. Child Name *

First

Last

School / Grade *

Birth Date *

Gender *

2. Child's Name *

First

Last

School / Grade *

Birth Date *

Gender *

3. Child's Name *

First

Last

School / Grade *

Birth Date *

Gender *

4. Child's Name *

First

Last

School / Grade *

Birth Date *

Gender *

5. Child's Name *

First

Last

School / Grade *

Birth Date *

Gender *

Emergency Contact Information

Emergency Contact Name *

First

Last

Relationship to family *

Emergency Home or Cell Phone *

Emergency Work Phone *

Emergency Contact Email *

Medical Information & Release

Insurance Carrier *

Name of policy holder *

Policy / Group Number *

List all known medical conditions *

List all known allergies (food, medicine, etc.) *

List any important medications currently taking *

Additional information to insure the proper card & safety of your child / children *

I, the undersigned, have legal custody of the minor(s) listed on this form and have given my consent for him/her/them to attend events being organized by Liberty Bible Church. I understand that there are inherent risks involved in any ministry event, and I hereby release Liberty Bible Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s/children’s involvement. I affirm that the health insurance and medical information provided is accurate at this time. If this information changes, I will notify Liberty Bible Church as soon as possible. In the event that he/she/they is/are injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. I acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by my health insurance provider. Should it be necessary for my child/children to return home from an event due to either medical or disciplinary reasons, I will also assume all transportation costs.

Checking "Yes" below is considered your digital signature for the purposes of this authorization. By checking here, you are consenting to the use of your digital signature in lieu of an original signature on paper. You have the right to request that you sign on a paper copy instead. By checking "Yes" below, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. Your agreement to use a digital signature with us will continue for the full duration of 2022 or until you notify us in writing that you no longer wish to use a digital signature.

Parent / Guardian Name *

Date Submitted *

Digital Signature *

Yes

Multimedia Release

I, the undersigned, hereby authorize Liberty Bible Church to use photos or videos of my child/children on printed materials and digital platforms for informational and promotional purposes. Though the privacy of my child/children will be respected, photos or videos of my child/children shall remain the exclusive property of Liberty Bible Church and shall be used without notice or compensation.

Parent / Guardian Name *

Date Submitted *

Digital Signature *

Yes

Submission of this form indicates that you understand what is contained in this authorization. This authorization shall remain effective from January 1, 2022-December 31, 2022 unless sooner revoked in writing by the parent or guardian.

Submit

If you would prefer a paper copy of this form, one can be obtained from the church office during business hours. You can also download the PDF file below. The PDF will need to be printed out and submitted to the church office.

Liberty Bible Church Medial Release Form 2022.pdf
File Size:	182 kb
File Type:	pdf

Download File