Authorization of Medical Release - Curtis Baptist School

Authorization for Medical Release

CURTIS BAPTIST SCHOOL

Authorization for Medical Aid and Release of Liability

General Information

Student's Full Name *

What Sports do you plan on playing this year? *

Social Security #: *

Date of Birth: *

Grade Entering *

Name of Parent/Guardian: *

Home Phone: *

Father's Work Phone: *

Father's Cell Phone: *

Mother's Work Phone: *

Mother's Cell Phone *

Parent's Email Address *

Emergency Contact (Other than parent): *

Insurance Information

Name of Insured: *

Policy #: *

Name of Insurance Company: *

Medical Information

List any medicines that the student is allergic to:

List any allergies and the treatment method:

List any medical history that trip counselors should be aware of (fainting, seizures, asthma, etc):

List any medications the student might have in their possessions at a school function:

Release of Liability

Please list any activities in which your child is not to participate:
Curtis Baptist School, including employees and representatives of the aforementioned organizations, shall be held harmless from any suit, action, damages, or claims at law or otherwise, resulting from or arising out of any injury, accident, or illness that may befall the student-athlete / my child and/or his/her property while participating in Curtis Baptist School sponsored events or activities. If the participant is a minor, this covenant is applicable to the afore signed and his/her parents or guardian.
The undersigned parent or guardian hereby authorizes the sponsor, sponsor's agent, or employees to take such action as may be necessary for the medical care or treatment including the administration of medication, performing of surgery, or such other action as needed in the event on injury or illness of participant when parent or guardian cannot be reached for authorization. In the event the above-authorized refuse or are not able to act, Curtis Baptist School personnel are authorized to act as set forth above. This authorization may be presented to medical personnel to seek further authority.

By placing your initials in this box, you are officially signing this form.

Signature of Participant *

Today's Date *

Signature of Parent/Guardian if participant is under 18 *

Today's Date *