B Students Medical Waiver

Student Ministry Emergency Contact and Medical Release Form

Student's First Name

Student's Last Name

Birthdate

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Student's Phone Number

Grade (if summer, last grade completed)

Mother's First Name

Mother's Last Name

Mother's Place of Employment

Employer's Phone Number

Email

Father's First Name

Father's Last Name

Father's Place of Employment

Employer's Phone Number

Email

If there are any special circumstance involving parents/step-parents, please check "yes" below and give details in the box provide. If this does't apply to your student, please select "N/A"

Yes

N/A

If yes, explain situation.

Allergies, medical conditions, medications, limitations, any special instructions.

Name of Insurance Provider

Insurance Provider Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Insurance Provider Phone Number

Policy Number

IMPORTANT!!! READ AND SIGN IN BELOW 
Brandon First Methodist Church carries medical payment and liability insurance to cover expenses that would relate to a bus accident. We also carry liability that covers the legal liability of the church for an accident. Brandon FMC assumes NO FINANCIAL RESPONSIBILITY for medical expenses resulting from personal accidents or illness. Brandon FMC does not carry medical reimbursement insurance.

I accept financial responsibility for the well-being of the above-named person and authorize the group sponsor to seek needed medical help. I also authorize the attending physician to provide any needed medical treatment. I hereby waive any claim for damages for personal injuries or loss of property not caused by negligence of the church or its agents or employees.

Signature