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Medical Release Form MBC

Student Name:

Grade:

DOB:

School:

Parent or Guardian Name(s):

Parent Email:

Address:

Best Contact Number:

Allergies / Sensitivities ?:

Allergies - food, medication, environmental, or anything else we need to know.:

Emergency Contact phone #1:

Emergency Contact phone #2:

In the event that an emergency happens and we can not reach parent/legal guardian, please list another responsible adult we could call and provide a phone number::

Phone Number:

Emergency contact relationship to student:

Health Insurance Company & Responsible Party:

Policy #:

Group #:

Doctor's Name:

Preferred Hospital:

Immunizations up to date?:

Date of last Tetanus vaccination:

Medications taken on a regular basis:

Medical Consent (if individual is under 18 years of age): I hereby state that the above information is true and correct. I understand that in the event of an emergency with my child, every effort will be made by adult sponsors of the Student Ministry of MBC to notify me. If they are unable to reach me/emergency contact listed above, I authorize same responsible adults to authorize any necessary medical treatment for my child.:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

February 23, 2022 10:48 am CDT

Medical Release Form MBC Uploaded by Sherri Hatcher - formsmbc@midlothianbible.org IP 12.14.174.178