FEFC Medical Release Form for Minor
Name __DOB ____ Age ______ Sex ______
Address ___ ______City Zip __________
In Emergency Notify: __________________________
Ph #1 ________________ Ph#2 _______________________ Ph#3 ____________________
Doctor: Phone __________
Date of last tetanus booster shot _____ 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____.
My Commission Expires: