Student Medical Release Form 2024

Please fill out this form and click submit. This form only needs to be completed once per year for each student and is required for all overnight student events.
Effective Dates: January 1, 2024 - December 31, 2024
 
 
 
 
Please select one option.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any, action of protection is required on account thereof.  Submit this notification in writing and attach it to this form.  Include names of medications and dosages that must be taken.  
 
 
 
Parent Release and Consent to Treatment:
 

who is under eighteen years of age, and I am fully competent to sign this Release and Consent. I give permission for Participant to participate Westminster Baptist Church’s Student Ministry activities for the period from January 1, 2024 to December 31, 2024. I acknowledge that the nature of Westminster Baptist Church’s Student Ministry activities may expose Participant to hazards or risks that may result in Participant’s illness, personal injury, or death and I understand and appreciate the nature of such hazards and risks. In consideration of Participant being permitted to participate in Westminster Baptist Church’s Student Ministry activities, I hereby accept all risk to Participant’s health and of Participant’s injury or death that may result from such participation, and I hereby release Westminster Baptist Church, its pastors, ministers, employees, agents and representatives from any and all liability to Participant, Participant’s personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to Participant’s property and for any and all illness or injury to Participant’s person, including death, that may result from or occur during Participant’s participation in Westminster Baptist Church’s Student Ministry activities, whether caused by negligence of Westminster Baptist Church, its pastors,  ministers, employees, agents or representatives, or otherwise.


I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR PARTICIPANT’S INJURY OR DEATH OR DAMAGE TO PARTICIPANT’S PROPERTY THAT OCCURS WHILE PARTICIPATING IN Westminster Baptist Church STUDENT MINISTRY ACTIVITIES AND TRIPS.  




I further state that I have the power to consent to medical treatment for Participant, and I authorize and appoint a representative of Westminster Baptist Church Student Ministry bearing this document as my agent to consent to medical treatment of Participant when I cannot be contacted to so consent, such medical treatment to include, without limitation, emergency room treatment; X-ray and other diagnostic examination; anesthetic treatment; medical, dental, or surgical examination or treatment; and general hospital care.  No prior determination of life threatening emergency or danger of serious or permanent injury resulting from delay of treatment need be made under this authorization.  




I will indemnify and hold harmless from any expense or claim of any nature any entity that provides or causes to be provided examination, treatment, or hospital care under this authorization and conditionally agree to make or cause to be made, by assignment of third-party benefits or otherwise, full and complete payment for such examination, treatment, or hospital care.   


 

Description

Please fill out this form and click submit. This form only needs to be completed once per year for each student and is required for all overnight student events.