Ingleside Baptist Church 

Permission for Activity Participation and Medical Treatment

Activity /Event ________________________________________   Date of Event________________

Participant Name___________________________________________________________________
                                        (Last)                                           (First)                                       (Middle)

Address: _______________________________________________ State:_______ Zip:___________

Home Phone: _______________________ Social Security Number:_________________________

Insurance

Insurance Company: _________________________________________________________________

Address of Insurance Company: _______________________________________________________

Insurance Company Phone Number: ___________________________________________________

Policy Number: ________________________________ Group Number:_______________________

Medical

Medical Conditions: __________________________________________________________________

Any Allergies: ________________________________________________________________________

Current Medications: _________________________________________________________________

In Case of Emergency

Name of Person(s) To Contact: _________________________________________________________

Address: _____________________________________________________________________________

Home Phone: ___________________________ Work Phone:__________________________________

Authorization

I, who by law may do so, authorize the administration of emergency medical treatment to she/he who is subject of this form. I understand that all reasonable safety precautions will be taken at all times by Ingleside Baptist Church or it's agents in the event of any accident, injury, or disease incurred by the subject of this form. I understand that in the event medical treatment intervention is needed, every attempt will be made to contact the person(s) above immediately.

I hereby release Ingleside Baptist Church, it's staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain during this activity.

Signature of Parent/Guardian _______________________________________ Date______________