WESTSIDE BAPTIST CHURCH

Medical Permission and Release Form

Name________________________________________________________________________Age__________

Address__________________________________________________City_____________ST___ZIP_________

In case of emergency notify: ___________________________________Home Phone:_____________________

Work Phone:___________________Cell Phone:_____________________

Family Physician_________________________________  Phone to Physician:_____________________

Family Insurance Co._____________________________ Policy #___________________

Immunizations: (please circle) Tetanus  Y N        Polio Booster Y N Measles Y N Mumps Y N

Approximate date of last TETANUS ________________

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PAST MEDICAL HISTORY

Asthma___ Sinusitis___ Bronchitis___ Kidney trouble ___ Heart Trouble____

Diabetes___ Dizziness___ Stomach problems___ Hay fever____

Allergies: Food_______________________________________________________________________

Medications__________________________________________________________________

Insect Bites___________________________________________________________________

Poison Ivy etc._________________________________________________________________

Previous Operations or serious illnesses:___________________________________________________________

Any Current Medications you are taking:___________________________________________________________

Special Diet? (name)___________________________________________________________________________

*******************************************************************************************GENERAL HEALTH STATEMENT

The person herein described has permission to engage in all prescribed activities except as noted.  List activities he/she cannot engage in:______________________________________________________________________

He/she is believed to be in satisfactory health and free from communicable disease, and there are no apparent contradictions  to participating in routine activities.

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PERMISSION FOR TREATMENT

My permission is granted for the Pastor or sponsor in charge 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 all sponsors, employees of Westside Baptist Church and Westside Baptist Church from any and all claims, demands, actions or cause of action, past, present, or future arising out of any damage or injury while participating in any activity sponsored by the church.

Dated this________ day of ___________, 2004 State of ___________County of _____________

Signature of parent/guardian___________________________________________________________________

On this the _________day of __________, 2004, ____________________(name of parent) personally appeared before me and in my presence executed the within and foregoing permission and release form.  Witness my hand and official seal this ______day of ________, 2004.   Signature of Notary Public __________________________.

 My commission expires ________________ Notary Public.