First Baptist Church of Maud , Texas

Permission/Medical Release Form

Name __________________________________________________Grade_____ Age _____Birth date_____________

Address _______________________________________________________________ Phone_____________________

Social Security # ______________________________________ Church_____________________________________

Parent or Guardian ________________________________________Work or Cell Phone_______________________

Other Emergency Contact _________________________________________Phone____________________________

Insurance Information:

Company __________________________________________________________Phone _______________________

Name of Insured _______________________________________Policy or Group #____________________________

 If there are any special medications that have to be taken during the trip, please inform a First Baptist Church representative of this so they can insure proper administration of the medication.

Medications and instructions or any allergies:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

To Whom it May Concern:

The undersigned does hereby give permission for my child,______________________________________

to attend and participate in the activities sponsored by First Baptist Church Maud.

I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned will be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant this authorization.  Furthermore, I [and on behalf of my child-participant under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

The undersigned further hereby agree to hold harmless and indemnify said churches, event coordinators, Baptist Association, their directors, employees, and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

Should it be necessary for my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by First Baptist Church Maud.

I, ________________________________, will not hold First Baptist Church Maud, their employees, volunteers and/or sponsors liable in the event of an accident or injury involving my child.

 Signature of Parent or Guardian ___________________________________________ Date________________________________