Student Medical Waiver/Liability Form

ALL STUDENTS ARE REQUIRED TO FILL OUT A MEDICAL WAIVER FORM TO ATTEND ANY TRIP WITH CAMPBELLSVILLE BAPTIST CHURCH.

Date

Student Name

Address

Student Date of Birth

Phone

This address will receive a confirmation email

Parent/Guardian Information

Name

Address

Phone

This address will receive a confirmation email

Emergency Contact Information

Name

Phone

Family Physician Information

Name

Phone

Insurance Information

Insurance Company Name

Policy Number

Medical History

Check All That Apply Asthma Kidney Problems Diabetes Heart Problems

Food Allergies

Drug Allergies

Insect Bites/Stings Allergies

Other Allergies

Consent for Treatment

My permission is granted for Campbellsville Baptist Church staff to obtain necessary medical attention in case of sickness or injury to my child. Also, I understand that as a participant my child may be photographed or videotaped during normal CBC activit

Description

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Student Medical Waiver/Liability Form

Description

Please Fix the Following