Medical Release Form

Name of Child  ___________________________________________________

Age _________

Parent/Guardian’s Name (s) __________________________________________

Address  ________________________________________________________

Address of child if different from above:
________________________________________________________________

Home phone  ____________________Cell phone  __________________________

Alternative contact person  ____________________________________________

Relationship  _______________________________________

Phone  ________________________________

I hereby authorize the emergency medical treatment of my child while under the care and custody of First Baptist Church of Minonk, IL and hold harmless the church and its agents or assigns and representatives, including volunteer workers for any harm deemed to arise from the said treatment or the lack of said treatment.  I understand that First Baptist Church of Minonk, IL nor its workers are responsible for administering any medications required to be taken by my child and this is the sole responsibility of my child; and I acknowledge that First Baptist Church of Minonk IL, nor any of its workers are authorized to make any medical diagnosis nor administer any medical procedures, excepting those actions deemed proper and necessary in an emergency where they may act as a “Good Samaritan” and render aid and assistance as allowed under the laws of Illinois, whose jurisdiction is agreed to by myself as applicable.
A copy of this document shall be valid as though it were an original.

Date: ___________________

Signature:________________________________________

Printed:_________________________________________________________

Child’s Full Name:_______________________ Date of Birth:________________

Medical Insurance Co.:____________________ Policy #:____________________

Doctor’s Name: _________________________ Phone #:____________________

Special Needs or Medical Concerns:______________________________________

(If more space is needed, please write on the back of this form)

LINK TO DOWNLOAD FORM: Medical Release Form