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Bible Search
Permission Form

This form is for information purposes only. If you need to have one, request one from someone in Christian Education.

 

c Adult

c Youth

c Preteen

c Children

First Baptist Church

 

2143 Judson Dr.

Dubuque, Iowa 52001

Phone: (563) 583-6289

September 2018 to August 2019 Medical Release, Publicity Notification, and Power to Authorize Medical Treatment

 

Personal Information

Name ____________________________________

Birth date _____________ Grade in School _________

Home Phone ________________Cell Phone _______________

Physical Address _______________________________________________

City & State _____________________

Mother/Guardian’s Information: (if under 18 years old)

Name ______________________________________

Relationship to person noted above: _________________________

Employer __________________________ Work # _____________

Cell # ____________ Other Contact # _____________

Father/Guardian’s Information: (if under 18 years old)

Name ______________________________________

Relationship to person noted above: _________________________

Employer __________________________ Work # _____________

Cell # ____________ Other Contact # _____________

 

Medical Information

MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages if necessary.

 

1. List any medical conditions you have (asthma, diabetes, epilepsy, etc.):

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

 

2. List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

 

3. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

 

MEDICATION: List all medications the youth will take during any youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins.

 

Medication Name Dose Treatment for Dispensing Instructions

 

Example: Zyrtec 5mg Seasonal allergies Take one pill daily in the morning with food

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

 

Over-the-Counter Medication Permission

Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?

 

c No. Contact me or get medical help if my child has any minor medical concerns.

Parent/Guardian

Signature___________________________________________________________

 

c Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.

Parent/Guardian Signature___________________________________________________________

 

Please list any specific instructions or medical directions pertaining to this individual: __________________________________________________

____________________________________________________________________

____________________________________________________________________

 

 

Physician’s Name ___________________________________________________

Physician’s Phone # ________________________________________________

Dentist’s Name _____________________________________________________

Dentist’s Phone # __________________________________________________

Preferred Hospital by Insurance ____________________________________

 

Medical Insurance Information

Name of Medical Insurance Company _____________________________

Name of Insured ______________________________

Insurance Company’s Phone # _______________________________

Group or Policy # ________________________________

  1. attach a copy of your insurance card)

 

Parent/Guardian Responsibility Notification

It is your responsibility as the parent or guardian of the minor child named on this document to notify First Baptist Church of Dubuque, Iowa of any information change regarding the safety and well-being of the minor listed on this document between the date this document is executed and August 31, 2019. This includes address or phone number changes, custody or guardianship status of the minor listed on this document, allergies, allergies to medication, and medication currently being taken or medication discontinued, insurance company coverage, insurance policy or group number change since the last medical form on file. It is your responsibility to check with First Baptist Church of Dubuque, Iowa to determine if the current document on file at First Baptist Church, Iowa contains all the current emergency and medical information criteria for the safety and well-being of your minor child. Any information changes will require a new medical release document to be on file at the church.

 

Acknowledgement & Agreement of Rules

I will read the rules governing trips/events and I will discuss them with my minor child. I understand that if the above named child becomes a discipline problem, the above minor child will be sent home at the expense of their parent or legal guardian.

 

Functions & Activities Notification

It is my understanding that participating in the programs, recreational and other activities of First Baptist Church is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. I understand that at some church functions my child may ride in a private vehicle. Some activities have only one adult present. (Signing this waiver releases your student or child to participate in these and other activities with full knowledge that there may not be two adults present at all times.)

 

Publicity Notification

On occasion, First Baptist Church of Dubuque, Iowa takes photographs or makes an audio or video recording of children and/or adults involved in activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in First Baptist Church publications/website/advertising materials to let others know about our ministries. In addition, local news organizations may hear of our activities or events, and our church may invite or allow them to photograph or record our events for new reporting on special interest features. I consent to the use of any such audio or visual record of the child named on this document, or me, if I am participating, to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, video, and audio recordings. Furthermore, I give permission for the child (or self) to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media.

 

c I authorize the Publicity Notification.

Parent/Guardian

Signature___________________________________________________________

 

c I do NOT authorize the Publicity Notification.

Parent/Guardian Signature___________________________________________________________

 

Medical Treatment Authorization & Release of Liability

By execution of this document, I hereby grant to the pastors or any other adult approved by ministry of First Baptist Church of Dubuque, Iowa, individually and separately, my permission and the right and power to consent to medical and surgical treatment during an emergency involving an immediate danger to the health and safety of my minor child (or self) named in this document, in the event I cannot be reached in an emergency. I also hereby give my permission to the physician, hospital, emergency personnel, or clinic selected by a Pastor, or an adult selected by him, or representative of First Baptist Church of Dubuque, Iowa, individually or separately, to administer or order injection, surgery, or other medical treatment that may be necessary to insure the health, well-being and safety of the minor child (or self) named in this document. I also authorize the proper emergency person or persons selected by the above named on this document. I also authorize the proper emergency person or persons selected by the above named on this document. I also authorize the proper emergency person or persons selected by the above named, individually and separately, the right to transport or authorize transport for my minor child at their discretion in case of an emergency. I also give them the authority and power to execute any forms and documents necessary to authorize the medical and surgical treatment to my minor child named on this document, in the event that the other conditions contained in the paragraph above have been met. I grant the above permission to be in effect from the date this document is executed through August 31, 2019. I also realize it is my responsibility to update any information that changes in this document should it change anytime between the date this document is executed and August 31, 2019.

 

c I do NOT authorize the Medical Treatment Authorization & Release of Liability. I understand that 911 will be called in case of an emergency.

Parent/Guardian

Signature___________________________________________________________

 

c I do authorize the Medical Treatment Authorization & Release of Liability.

Parent/Guardian Signature___________________________________________________________

 

 

 

Signature Acknowledgement

 

 

____________________________________________________________________

  1. Name (print) Parent/Guardian Name (print)

 

 

X___________________________________________________________________

Parent/Guardian Signature Date

 

 

____________________________________________________________________

Street Address City, State, Zip

 

 

____________________________________________________________________

Parent/Guardian Email Phone