Winter Blast

Medical Release Form

First Name: _________________________ Last Name: _______________________________

MI: ______          Gender: male / female Birth date:  _____/_____/__________

Address: ___________________________________________________________________

City: ___________________________________ State: ________ Zip: _________________

Emergency Contact: ________________________________ Relationship: _______________

Emergency Phone: ______-_______-____________ or ______-_______-_____________

Last Tetanus Shot (if known): _____/ _____/ _________

Insurance Company: ___________________________________ Phone: ________________

Policy Number: ______________________________ Physician: _______________________

Primary Insurance Subscriber’s Name: ____________________________________________

Allergies: ___________________________________________________________________

Current Prescription Medications and Instructions: __________________________________

Special Instructions: _________________________________________________________

Medical Release Waiver

I__________________________, parent and/or legal guardian of ______________________, a minor, hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give my child, the said minor, my express permission to attend Winter Blast, January 27-29 2012.  I further expressly grant my permission for my child to participate in all activities of said event.  I have listed said minor’s physical or medical problems that may need attention. In the event of an emergency, necessitating medical or surgical attention, I hereby consent and give my permission to Roseville Baptist Church, or its representatives or any attending physician, to make such decisions and to perform such medical treatments upon said minor which may, in their sole discretion, be necessary and proper under the circumstances.  I do release, acquit, discharge, and covenant to hold harmless the Roseville Baptist staff or its representatives, from any and all actions, damages, liabilities arising out of the treatment of any sickness or accident incurred by said minor while attending the skit trip.  I also give permission for the following medications to be given to my child, if the need should arise, during the ski trip: Tylenol, Ibuprofen (Advil), Tums (or generic), Pepto Bismol,

Other:__________________________________

Parent/Guardian Signature: __________________________________ Date: _______________