Parental Consent Form

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  Consent and Release Form for Church Sponsored Activity

Cornatzer Baptist Church

Phone 336 998-4399

I, hereby consent for my child to attend and participate in church activities of Cornatzer Baptist Church. In case of injury to my child, I do authorize an adult sponsor of the church to make any necessary emergency medical decisions for my child. This includes first aid, hospitalization, medical treatment and transportation for my child if needed.

I understand I will be contacted as soon as possible about injuries and or treatment to my child.

EMERGENCY INFORMATION

(Please print all the following information)

Child's Name    ___________________________________

Emergency Numbers: Cell  _________________Home ___________________Other________________

Father's Name __________________________                Mother's Name __________________________

                        First, Last                                                                                               First, Last              

Current grade  ____________ Date of Birth_______________ Current Weight _________lbs.

Complete Home Address____________________________________________________

City ____________________________________State _________Zip____________

Family Physician _________________________ Phone_________________

INSURANCE INFORMATION

(Please print all the following information)

Insurance Provider __________________________________

Policy/ Group Number_____________________________

Billing Address______________________________________________________________

City ____________________________________State_________ Zip____________

I further state I have carefully read and understand the foregoing release and know the contents hereof are true and sign this release as a legally binding agreement. Any medical conditions, allergies, asthma or medications are listed below.

Medical conditions/ Allergies to be aware of: ____________________________________________________

Physical restrictions: __________________________________________________________________________

Medications and instructions: __________________________________________________________________

Date of last tetanus or booster:____________

Name and date of event: ____________________________________________

      I give Cornatzer Baptist Church permission to use photos that are taken containing the above mentioned minor on this event for use on the church web site or other church promotional uses.

Parent or Guardian Signature

 __________________________________            ______________________________ Date ________________

(Printed)                                                                                                                 (Signed)