MANTEO BAPTIST CHURCH 1 MEDICAL PERMISSION AND RELEASE FORM Participant Name: ___________________________________________________________________________________ Address: ______________________________________________________________________________________________ State: _____________ Zip: _____________ Phone: ________________________________________________ S.S. #: _________________________ Date of Birth: _____ / _____ / _____ Current Grade: __________ In the event of an emergency, provide the name and phone number of a friend or relative that can be contacted. Also provide insurance information. Name: _________________________________________ Phone: _______________________________________ Name: _________________________________________ Phone: _______________________________________ Insurance Company: ________________________________________________________________________________ Claims Mailed To: ___________________________________________________________________________________ Policy #: _______________________________________ Group #: _____________________________________ Physician’s Name: ____________________________________ Phone: _______________________________ MEDICAL HISTORY (Check all that apply) ☐ Asthma ☐ Sinusitis ☐ Bronchitis ☐ Kidney Trouble ☐ Heart Trouble ☐ Diabetes Allergies: Food: _________________________________________________________________________________ Drugs (list by name): ________________________________________________________________ Insect Stings/Bites: __________________________________________________________________ Previous Operations or Serious Injuries: __________________________________________________________ Current Medications (list by name): ________________________________________________________________ EMERGENCY AUTHORIZATION I hereby give permission to the medical personnel selected by the staff of Manteo Baptist Church, or the bearer of this document, to obtain necessary medical attention, x-rays, routine tests, and treatment in case of sickness or injury to the above named person from physician selected by the bearer of this document to hospitalize, to secure proper treatment for, and to order injections and/or anesthesia and/or surgery for myself as named on this form. I agree that any health provider may use a photocopy of this consent form as evidence of my consent. I hereby release Manteo Baptist Church or any adult supervisors of any liability. Responsible Party Signature: __________________________________________ Date: _________________ 1/1/2018 until 12/31/2018. I give consent to the Manteo Baptist Church 406 US Highway 64, Manteo, NC 27954 252-473-2840 MANTEO BAPTIST CHURCH 2 PERMISSION & MEDICAL AUTHORIZATION FORM Name of Participant: ______________________________________________ Date: ______________________ I (we) being 18 years of age or older, do for myself or on behalf of my youth or child hereby release, forever discharge and agree to hold harmless Manteo Baptist Church, the directors, professional staff and sponsors thereof, from any and all liability, claims or demands for personal injury, sickness, or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned youth/child participant that occur while I or the youth or child is participating in the above described event, trip or activity. Furthermore, I (we) do for myself or on behalf of my youth or child hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree to hold harmless and indemnify said church, its directors, professional staff, sponsors and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. I for myself or I (we) as the parent (s) or legal guardian(s) of this participant, hereby grant my (our) permission for him, her or me to participate fully in said event, trip or activity. Responsible Party Signature(s): _________________________________________________________________________________________________________ Date: ___________________________________ Expiration Date – 12/31/2018 Manteo Baptist Church 406 US Highway 64, Manteo, NC 27954 252-473-2840