2011 WHEREHOUSE Student Ministry Medical Release Form
Student Name: ____________________________________________________ Birthdate: ______ / ______ / ______
Mailing Address:___________________________________ City __________________ State ______ Zip ____________
Emergency Contact Name: ____________________________________________ Relationship __________________
Home Phone ______-______ - ______ Cell Phone ______- ______ - ______ Business Phone ______- ______ - ______
Health Problems/Activity Restrictions: __________________________________________________________________
Drug Allergies/Allergic Reactions: _____________________________________________________________________
Dietary Restrictions: ________________________________________________________________________________
Medications (must be in the possession of adult leader): ____________________________________________________
May Tylenol, Ibuprofen, Benadryl, Sudafed, Robitussin PM, Dimetapp, Cough Drops, Pepto Bismol be administered to
your child? Yes No Please attach a note if you checked ‘no’ or have any concerns.
Approximate date of last Tetanus shot: ________________________
Family Doctor: ________________________________________________ Phone Number: ______- ______- _________
Insurance Information: Medical Insurance Co. ______________________________ Policy #: ___________________
Important: Please attach copy of insurance card to this form!
It is mandatory that this form be filled out, signed and dated. Only a legally responsible Parent/Guardian may
sign this form.
1. I agree to hold harmless Bethlehem Church or its agents for any and all claims for injuries, illnesses, causes of
action, the rendering of emergency care, or liability related to participation in any church activity.
2. I further give permission for my child to be transported by church vans or other vehicles authorized by the Student
3. I, the undersigned, understand that if medical treatment is required, every effort will be made to contact me. In
the event that I cannot be reached in an emergency and my child requires treatment, I hereby give permission to
the physician selected by the Student Ministry staff to hospitalize, secure proper treatment for, and to order
injection, anesthesia or surgery for my child, as named on this registration form.
CHILD’S NAME: __________________________________________________________________________________
PARENT/GUARDIAN’S NAME: ______________________________________________________________________
RELATIONSHIP TO CHILD: _______________________________________________ DATE: ______/______/______
PARENT/GUARDIAN’S SIGNATURE: _________________________________________________________________
Please complete and submit to the WHEREHOUSE Student Office at the address below at the same time as Registration.
Bethlehem Church • 3100 Bethlehem Church Street • Gastonia, NC 28056 • 704-823-1600