Students: Medical Release Form

Fill out for participant

Your name *

Email address *

Gender *

Birthday *

Student Or Adult Leader *

Student

Adult Leader

Parents will be notified immediately in case of serious illness or accident. Please list telephone number where you may be reached.

Other Emergency Phone

Allergies & Medications

Medication Allergies: *

Food Allergies: *

List any medication(s) your child is presently using on a regular basis: *

E-Signature & Consent

I Certify *

This is to certify that I the undersigned give permission for my child to receive medication and/or medical treatment if necessary in the event of illness or accident. I understand that every effort will be made to assure the safety of my child. I give Parkview Baptist Church staff or another PBC adult chaperone permission to make a decision concerning emergency treatment during PBC youth sponsored events.

E-Signature *

Above is an electronic signature of my name that, for purposes of this Agreement, I adopt as my signature. I agree that this electronic signature is the legally binding equivalent of my handwritten signature on paper. I waive any and all claims that the electronic signature below does not legally bind me to the terms of this Agreement. By signing, I understand that I am signing this Agreement with the intent of being bound by all of its terms. I further acknowledge that I have read and fully understand the terms of the Agreement; I voluntarily agree to be bound by this Agreement; and I certify that I am 18 years of age or older.