Student Medical Waiver/Liability

Please fill out this form and click submit.

A parent or legal guardian must complete and sign a separate Student Medical Waiver and Liability Form for each student in their household who will be participating in any trip sponsored by Campbellsville Baptist Church. A completed form must be on file prior to the student's participation.

Student Information

Student Name

Student Address

Student Date of Birth

Student Gender

Please select all that apply.

Male Female

Student Phone

Student Email

This address will receive a confirmation email

Parent/Guardian Permission to Text/Email Student (if under age 18)

Please select all that apply.

Yes No

Parent/Guardian Information

Name & Relation to Student

Address (if different than student address)

Phone

This address will receive a confirmation email

Emergency Contact Information

Name & Relation to Student

Phone

Family Physician Information

Name

Phone

Insurance Information

Insurance Company Name

Policy Number

Medical History

Check All That Apply

Please select all that apply.

Asthma Kidney Problems Diabetes Heart Problems

Food Allergies

Drug Allergies

Insect Bites/Stings Allergies

Other Allergies

Parent/Guardian Consent

Medical Authorization

Please select all that apply.

I authorize the staff and volunteers of Campbellsville Baptist Church to obtain necessary emergency medical treatment for my child if I cannot be reached or if immediate medical attention is required.

Assumption of Risk and Liability Release

Please select all that apply.

I release Campbellsville Baptist Church, its staff, volunteers, and representatives from liability arising from my child's participation in activities, except in cases of gross negligence or willful misconduct.

Photo and Video Release

Please select all that apply.

I give Campbellsville Baptist Church permission to use my child's photograph or video for promotional and ministry purposes, including print, the church website, and social media.

Annual Authorization

Please select all that apply.

This Student Medical Waiver and Liability Release Form is valid for and applies to all Campbellsville Baptist Church student activities, events, trips, and transportation occurring during the current ministry year.

Parent/Guardian Signature

Date

Description

Please fill out this form and click submit.

Student Medical Waiver/Liability

Description

Please Fix the Following