Date: _________________________

Name of student: ______________________________________________  Going into grade ____________________

Address: _____________________________________________________________________________________________

Person to contact in case of emergency: _____________________   Cell Phone number _______________________________

Alternate Contact Person: ________________________________   Cell Phone number _______________________________

I give the following persons permissions to pick up my child: ________________________________________________

I give permission for my child to have their pictures posted on the church facebook page, website, etc.for promotional purposes
     Yes  /  No

Medical Information
If your child should require medical attention for injuries received or illnesses contacted prior to activity, please send us the
necessary information to give them proper medical care during their time with us in our activity.  If you have medical insurance,
your carrier will be billed for medical charges in the case of illness or injury while your child is in our care.

Insurance Company: ________________________________  Name on Policy _____________________________________  

Policy # __________________________  Group # _______________________________

Family Doctor ______________________________________ Phone ________________________________

Dentist ___________________________________________ Phone ________________________________

Any pre-existing or present medical conditions _______________________________________________________________

Name and dosage of any medications that must be taken _______________________________________________________

List Allergies: ________________________________________________________________________________________

Any major illnesses during this past year? ___________________________________________________________________

Date of last tetanus shot: _________________________________  contact lenses  yes / no

Release and Wavier
I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons
listed on this form.  In the event I cannot be reached in emergency during the activity dates shown on this form, I hereby give my
permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order
injection, anesthesia, or surgery for my child as deemed necessary.  I understand all reasonable safety precautions will be taken
at all times by the Eastport Baptist Church and its agents during the events and activities.  I understand the possibility of
unforeseen hazards and know the inherent possibility of risk.  I agree not to hold Eastport Baptist Church, its leaders,
employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

Signature of parent/guardian:__________________________________________ Date: ______________

Any special or unique needs of this child, please write out on the back of this form.  Include family issues, relevant experiences,
special learning disabilities, or anything that will help us in working with your child

5910 N. M-88 Hwy
PO Box 2
Eastport, MI 49627
ph: 231-599-2122
Eastport Baptist Church Medical Release Form