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General Permission And Medical Liability Release Form

2011
(Please Print Clearly)
Name:__________________________________________________________ Gender:
M or F (circle)

Azalea Baptist
Church
3314 East Little
Creek Road
Norfolk, VA 23518
(757) 588-7000

Social Security Number:___________________________________________


Age:_______
Home Address:
_______________________________________________________________________
City: ________________________________________________________State:_____
Zip:___________
Home Phone: __________________________________________Date of Birth:
______/______ /______

Signature of Parent or Guardian: _____________________________________________________________ Date:


____________________
Printed Name of Parent or Guardian signed above:
________________________________________________________________________
Signature of Student: ______________________________________________________________________
Date:_____________________

General Permission And Medical Liability Release Form


2011
(Please Print Clearly)
Primary Parent/Guardian(s)

Medications (Name/Dosage/Purpose):

Name:___________________________________________
______

Regular:
________________________________________________________

Work
Phone:___________________________________________
_

Short term: _______________________________________________________

Cell
Phone:___________________________________________
__
Name:___________________________________________
_____
Work
Phone:___________________________________________
_
Cell
Phone:___________________________________________
__
Home Phone (If
Different):__________________________________
Address (If Different):
_____________________________________
__________________________________________________
_____
Alternate Emergency Contact:
_____________________________
____________________________Relationship: ________________
Contact Phone:
__________________________________________
__________________________________________________
_____
Family
Physician:________________________________________
_
Phone:___________________________________________
_____
Medical Insurance Information
Company:________________________________________
_______
Subscriber
Name:________________________________________

Over the counter medications allowed to take:


___________________________
___________________________________________________________
_____
Does the student wear contact lenses? _______Type?
___________________
Date of last Tetanus Shot
___________________________________________
GENERAL PERMISSION: (Please sign at the bottom)
I give the participant listed on this form permission to
participate in Azalea Baptist Church ministry events and
outings. I realize that this is a general form to be placed
on file in the student ministry office upon which the
church may use when necessary. As the parent/guardian
of the participant, I certify that the information provided
on this form is correct to the best of my knowledge. In
order that appropriate diagnosis and treatment may be
promptly carried out and so that no unnecessary delays
will occur, I give permission for such diagnostic,
therapeutic, and operative procedures as may be deemed
necessary for the person named. No major operation will
be performed, however, except in an emergency, without
a parent or guardian being contacted and fully informed. I
assume final responsibility for medical expenses
incurred by the participant, and for expenses
involved in returning the participant home for
medical reasons, or for any of the following
reasons: substance abuse, endangering the life of
another person, sexual, illegal or continual
misconduct. I understand that each individual is
responsible for his/her own insurance coverage during any
trip. I hereby release and forever discharge Azalea Baptist
Church, its staff, all sponsors, state conventions,
employees, and any designated individual in charge of
any trip from any legal responsibility, financial
responsibility, all claims, demands, actions or cause of
action, past, present, or future with respect to my
personal or childs participation in any church activity.
Please indicate your consent to the following
waivers: (circle)
PERSONAL PROPERTY WAIVER

Signature of Parent or Guardian: _____________________________________________________________ Date:


____________________
Printed Name of Parent or Guardian signed above:
________________________________________________________________________
Signature of Student: ______________________________________________________________________
Date:_____________________

General Permission And Medical Liability Release Form


2011
(Please Print Clearly)
Type Of
Coverage:_______________________________________
Group #:
_______________________________________________
Policy
#:________________________________________________
Phone
Number:_________________________________________
__

Agree/Disagree Initial _______


I understand that it is my responsibility to safeguard any
personal property I bring. I further understand that Azalea
Baptist Church will not under any circumstances be
responsible for any property lost, misplaced, or stolen.
PHOTO/VIDEO NOTICE
Agree/Disagree Initial _______
I understand that as a participant, my child may be
photographed or videotaped during normal activities and
that these photographs or videos may be used in other
materials or posted on the churchs website.

Please Describe Any Allergies or Medical


Conditions Which May Recur Or Be A Factor In
Medical Treatment:
__________________________________________________
_____
__________________________________________________
_____
__________________________________________________
_____

Signature of Parent or Guardian: _____________________________________________________________ Date:


____________________
Printed Name of Parent or Guardian signed above:
________________________________________________________________________
Signature of Student: ______________________________________________________________________
Date:_____________________