General Permission And Medical Liability Release Form

2011
(Please Print Clearly)
Name:__________________________________________________________ Gender: M or F (circle)
Social Security Number:___________________________________________ Age:_______

Azalea Baptist Church

3314 East Little Creek Road
Norfolk, VA 23518
(757) 588-7000

Home Address: _______________________________________________________________________

City: ________________________________________________________State:_____ Zip:___________
Home Phone: __________________________________________Date of Birth: ______/______ /______

Primary Parent/Guardian(s)

Medications (Name/Dosage/Purpose):

Name:_________________________________________________

Regular: ________________________________________________________

Work Phone:____________________________________________

Short term: _______________________________________________________

Cell Phone:_____________________________________________

Over the counter medications allowed to take: ___________________________

Name:________________________________________________

________________________________________________________________

Work Phone:____________________________________________

Does the student wear contact lenses? _______Type? ___________________

Cell Phone:_____________________________________________

Date of last Tetanus Shot ___________________________________________

Home Phone (If Different):__________________________________

GENERAL PERMISSION: (Please sign at the bottom)

I give the participant listed on this form permission to participate in Azalea Baptist
Church ministry events and outings. I realize that this is a general form to be
placed on file in the student ministry office upon which the church may use when
necessary. As the parent/guardian of the participant, I certify that the information
provided on this form is correct to the best of my knowledge. In order that
appropriate diagnosis and treatment may be promptly carried out and so that no
unnecessary delays will occur, I give permission for such diagnostic, therapeutic,
and operative procedures as may be deemed necessary for the person named.
No major operation will be performed, however, except in an emergency, without
a parent or guardian being contacted and fully informed. I assume final
responsibility for medical expenses incurred by the participant, and for
expenses involved in returning the participant home for medical reasons,
or for any of the following reasons: substance abuse, endangering the life
of another person, sexual, illegal or continual misconduct. I understand that
each individual is responsible for his/her own insurance coverage during any trip.
I hereby release and forever discharge Azalea Baptist Church, its staff, all
sponsors, state conventions, employees, and any designated individual in charge
of any trip from any legal responsibility, financial responsibility, all claims,
demands, actions or cause of action, past, present, or future with respect to my
personal or childs participation in any church activity.

Address (If Different): _____________________________________

_______________________________________________________
Alternate Emergency Contact: _____________________________
____________________________Relationship: ________________
Contact Phone: __________________________________________
_______________________________________________________
Family Physician:_________________________________________
Phone:________________________________________________
Medical Insurance Information
Company:_______________________________________________
Subscriber Name:________________________________________
Type Of Coverage:_______________________________________
Group #: _______________________________________________
Policy #:________________________________________________
Phone
Number:___________________________________________
Please Describe Any Allergies or Medical Conditions Which May
Recur Or Be A Factor In Medical Treatment:
_______________________________________________________
_______________________________________________________
_______________________________________________________

Please indicate your consent to the following waivers: (circle)

PERSONAL PROPERTY WAIVER
Agree/Disagree Initial _______
I understand that it is my responsibility to safeguard any personal property I
bring. I further understand that Azalea Baptist Church will not under any
circumstances be responsible for any property lost, misplaced, or stolen.
PHOTO/VIDEO NOTICE
Agree/Disagree Initial _______
I understand that as a participant, my child may be photographed or videotaped
during normal activities and that these photographs or videos may be used in
other materials or posted on the churchs website.

Signature of Parent or Guardian: _____________________________________________________________ Date: ____________________

Printed Name of Parent or Guardian signed above: ________________________________________________________________________
Signature of Student: ______________________________________________________________________ Date:_____________________