Permission Form
Medical/Permission and Release Form
Rima Ridge Baptist Church
This Form Is Valid For All Church-Sponsored Student (Preschool—Grade 12) Activities
Name: _________________________________________________________________________________
Age: ______
Social Security #: _________________________________ Date Of Birth: ____________________
Phone: _____________________
Address: _______________________________________________________
State: ______________________________________ Zip: _______________________
In Case Of An Emergency Notify:
Relationship: __________________________________ Phone: ____________________________
Family Physician: _______________________________ Phone: ____________________________
Family Insurance Company: _________________________________________________________
Policy Number: ___________________________________________________________________
Allergies: _________________________________________________
Food Allergies: ____________________________________
Penicillin Or Other Drug(S) (Name) _____________________________________________________
Insect Stings/Bites: ___________________________________________________________________
Poison Sumac, Oak, Or Ivy: _____________________________________________________________
Previous Operations or Serious Illness: ____________________________________________________
Any Current Medications: (List) _________________________________________________________
Special Diet: (Name) ___________________________________________________________________
Childhood Diseases: ( )Chickenpox ( )Measles ( )Mumps ( )Whooping Cough
Other: ________________________________________________________________________________
Permission For Treatment
My permission is granted for the Rima Ridge Baptist Church of Ormond Beach, FL, pastor, minister of music, youth, and education, other staff person, or other adult in charge to obtain necessary medical attention in case of sickness or injury to my child.
I, The Undersigned, Do Hereby Verify That The Above Information Is Correct And I Do Hereby Release And Forever Discharge All Sponsors And The Rima Ridge Baptist Church Of Ormond Beach, Florida, From Any And All Claims, Demands, Actions Or Causes Of Action, Past, Present, Or Future Arising Out Of Any Damage Or Injury While Participating In A Church-Sponsored Youth Activity.
Dated This ____________ Day Of ___________________ , 20_____ In The State Of Florida, County Of ___________________
________________________________________________ ______________________________
Signature Relationship
Notary may be required by the Church Staff:
On this the _______ day of __________________, 20_____, personally known by me and in my presence, executed within and foregoing medical/permission and release form. Witness my hand and seal.
My Commission Expires _________
Notary Public
Notary may required by Church Staff:
On This The _________ Day Of ___________ , 20_______ , personally known by me and in my presence, executed the within and foregoing medical/permission and release form. Witness my hand and official seal.
My Commission Expires
Notary Public
