Faith Baptist ChurchToday
Wednesday, June 19, 2013
Seeking God and Loving People
Faith Baptist Church
1602 N. Gallatin Rd.
Madison, TN 37115
Permission Slip, Health & Medical Release Form
(Fill in all fields then select all and print)
I give permission for to take part in the following activity:
Illness of any kind:
(Asthma, Diabetes, ETC)
(Food, Drug, ETC.)
Presently Taking any Medications Yes No
If yes, What Kind?
Emergency Contact Info
In case of emergency I can be reached at the following number:
If I cannot be reached Please Contact:(name and number)
I hereby give my consent for counselors to administer First Aid and/or place my child in a doctor's care if necessary.
In signing this form, I release and hold harmless Faith Baptist Church and all of its representatives of any liability resulting from any injury which may occur while participating in the activity listed above. This includes the time spent while traveling to and from said Activity.
(legal guardian's signature) (Date)