FEFC Medical Release Form for Minor
Name Address ___ In Emergency Notify: Ph #1 Doctor: Date of last tetanus booster shot __DOB ____ ______City Age ______ Sex ______ Zip __________ __________________________
________________ Ph#2 _______________________ Ph#3 ____________________ Phone _____ Date of Last Physical __________ _________
Allergic to: ______________________________________________________________________ Any medical needs _____ Medication presently being used Limitations or restrictions while at activity Insurance Comp/Policy # ________________________________
In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give Fellowship Church permission to act on my behalf in seeking emergency treatment for my child in the event the representatives of the church deem such treatment necessary. I give permission to those administering emergency medical treatment to do so, using those measures deemed necessary. I absolve Fellowship Church and their designated representatives from liability in acting on my behalf. SIGNATURE OF PARENT/GUARDIAN ___ __DATE __
STATE OF TENNESSEE COUNTY OF KNOX Before me, the undersigned, a Notary Public in and for the state and county aforesaid, personally appeared ____________________________________________________ (the legal guardian of the aforementioned Participant), with whom I am personally acquainted (or proved to me on the basis of satisfactory evidence), and who acknowledged that he/she executed the foregoing instrument for the purposes therein contained. Witness my hand and seal, this ________ day of _____________________, 20____.
______________________________________ Notary Public My Commission Expires: ____________________