Permission and Medical Release Form FBC JAX Youth Ministry

Permission and Medical Release Form
FBC JAX Youth Ministry Students Name:
Gender:
Grade:
Age:
Date of Birth:
I give permission for my son/daughter to attend all High School activities, to include but not limited
to, retreats, mission trips, camps, ministry events, and lock-ins. I also will allow my student to
participate in all recreational options that he or she chooses at any event. This will also include
any necessary travel to and from each event. ____________ (Initial)
If, for any reason, your student is limited from specific
activities, please note the limitations:
Will your student be taking any prescription or over the
counter medications while attending?
□ Yes □ No If so, please specify:
Prescriptions
Is your student allergic to any medications/food etc? If so, what?
How often to be taken:
Has your student had any injuries or surgeries that we should be
aware of?
I authorize administration of any over the counter medications by a health
care professional. I also authorize any health care professional to treat my child for injury or illness and to release information for insurance
purposes during the period of these activities. I further agree to assume obligation of doctor’s bills, telephone calls, or other expenses
relating to an emergency incurred during the period of these activities. ___________ (Initial)
M EDICAL IN SU RAN CE IN FO RM ATIO N :
Insurance Carrier:
__________________________________________________________________________________________
Policy Num ber:
_____________________________________________________________________________________________
Policy Holder:
______________________________________________________________________________________________
Home Phone: ______________________ Cell Phone: _______________________ Work Phone: _____________________
Best place to contact parent: ____________________________________________________________________________
Alternative person to notify in case of emergency if parent/guardian is not available:
_________________________________________ _____________________________ _________________________
Name Relationship Phone Number
(This permission form will be kept on record while your student is in the Youth Ministry. If there are any information changes during this time,
please submit an updated release form to the Ministry Center for our files.)
Parent or Guardian’s Signature:
Date:
3055 CR 210 West, Suite 106 Ÿ Saint Johns, FL 32259
904.366.1353