EASTMONT BAPTIST CHURCH

EMERGENCY MEDICAL AUTHORIZATION / RELEASE FORM

I hereby give authority to Steve Robinson, or the counselor in charge, to serve any necessary medical and / or surgical treatment for
my child in the event of an emergency due to sickness or accident with EASTMONT BAPTIST CHURCH, Montgomery, Alabama,
for the period of January 1, 2013 to December 31, 2013 while attending ANY AND ALL YOUTH FUNCTIONS AND TRIPS.
I understand that the parents will be contacted, but in the event they cannot be reached, the counselor in charge may choose a
reputable physician.

Name __________________________________Date of Birth _________________ SSN# __________________

Address __________________________________________________________________________________
City _________________________ State ________________ Zip __________________________________
Parents _____________________________ Phone (H) ________________ (W) ______________________
In case of emergency notify: __________________________ at ____________________________________
Family Physician _____________________________________Phone _______________________________
Family Insurance Company _________________________ Policy # _______________________________
Guarantors Name _______________________ SSN# ______________________ DOB _________________
***YOU MUST INCLUDE A COPY OF YOUR FAMILY INSURANCE CARD WITH THIS FORM***
PAST MEDICAL HISTORY
(CHECK GIVING APPROPRIATE INFORMATION)
_____ Asthma

_____

______ Asthma ( requiring rescue inhaler) ______ Sinusitis

Diabetes ______ Dizziness

_______ Upset Stomach

_______ Bronchitis

_____ Hay Fever _____Kidney trouble

_____ Other: _________________________________________________________________

Allergies:

Food_____________________________________________________________
Medications _______________________________________________________
Insects or Bites ____________________________________________________
Regular Medications ___________________________________________________________________________
Previous Operations or Illnesses: _________________________________________________________________
____________________________________________________________________________________________

RELEASE
I / We the undersigned, do hereby release, and remise and forever discharge all sponsors and EASTMONT
BAPTIST CHURCH, Montgomery, Alabama, 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 the event.
I/We also assume responsibility for any damages or destruction of property caused by the above child.
Date _________________ Signature of Parent or Guardian ___________________________________
STATE OF ALABAMA
MONTGOMERY COUNTY
I, the undersigned authority, a Notary Public in and for said County in said State, hereby certify that the
above named person who is known to me, acknowledged before me on this day that, being informed of the
contents of the medical release form has executed the same voluntarily for permission to the sponsors of
Eastmont Baptist Church to authorize any needed medical aid in case of emergency.
Given under my hand and official seal, this ______ day of _____________, 20____.
______________________________
NOTARY PUBLIC
My Commission Expires: _________________