MEDICAL/RELEASE FORM

Student Ministry, Elkins Lake Baptist Church

206 State Hwy 19, Huntsville, Texas 77340

(936) 295-7694

I hereby give my permission for ____________________________________________________(Student’s Name) to take part in various church-sponsored youth trips, outings and camps. I further give  permission and authorize the church representatives or sponsors of the trips or activities to secure needed medical treatment in the event that I cannot be reached for such permission. I release the church representative or sponsors form liability for accident or injuries on these trips or activities.

I further understand and agree that in the event that the above-named son/daughter be involved in activities that violate or compromise the rules, policies, or purposes of Elkins Lake Baptist Church as determined by the church representatives or sponsors, I will pay and accept full responsibility for release of my child to my custody and care.

Home Address __________________________________________________________________

City/State/Zip ______________________________ Youth’s Date of Birth ____________________

In case of emergency, please contact:

Parent or Guardian ____________________________ Phone No. ___________________________

Doctor _____________________________________ Phone No. ___________________________

Friend or Relative _____________________________ Phone No. ___________________________

List known food/drug allergies: _______________________________________________________

Medication taken regularly: __________________________________________________________

Date of last tetanus shot: ____________________________________________________________

Swimming: My youth is a: Non-swimmer ________ Fair _______ Good swimmer _________

Family Medical Insurance Company: ___________________________________________________

Policy Number or Group Number: _____________________________________________________

I have read and understand this Medical Release Form and represent that all of the information contained herein is true and correct. I, hereby, accept and assume all the risks of injury associated with the activities of Elkins Lake Baptist Church Student Ministry.

Unless terminated in writing, this release shall be effective for two (2) years from the date signed.

Signature ________________________________ Parent (Managing Conservator) or Guardian

STATE OF TEXAS

COUNTY OF ____________________________

Before me, the undersigned authority, on this day personally appeared ____________________________________

Known to be the person(s) whose name(s) is subscribed above, and acknowledged to me that he/she executed the same for the purpose therein expressed.

Sworn and subscribed before me this ___________ day of _________________, 20_____.

_____________________________________

Notary Public in and for ___________________

County, Texas

My Commission Expires_____________________