Medical Consent Form

Medical Consent Form (Side One)

Date completed__/__/__

·  For persons participating in church–related and authorized activities of The First Baptist Church, Trussville, AL

·  Adult participants may complete for themselves.

·  Completion by parents/guardian is necessary for persons under nineteen (19) years of age.

Name of Participant:______

Date of Birth:______Age______Sex______

Home Address:______City:______State:______Zip:______

Home Telephone:______Business phone:______

In case of emergency, please notify: (2 contacts, if possible)

Name______Name______

Phone(s)______Phone(s)______

Address:______Address:______

City/State:______City/State:______

Medical History Information

Family Physician’s Name:______Phone #______

Address:______

City/state/zip:______

Please list other physician’s names/address/phone numbers who should be consulted in the event of emergency or medical problems:

______

______

Dentist’s name and phone number (and orthodontist, if applicable)______

Is the participant allergic to any of the following : (Please check)

Penicillin______Other, Please explain:______

Other Drugs, please indicate ______

Insect Sting ______

Ivy Poisoning______

Does this participant have any medical or health problems, chronic or recurring illness or illnesses?

( ) Yes ( )NO If yes, describe the problems or illnesses:______

______

Indicate the date of last tetanus shot:______

Are there any activities, such as strenuous activities, to be restricted?______

Are you (the participant) on any medications? ( )Yes ( )No

If yes, please state the medication______

______

If so, will you (the participant) be bringing the medications to be taken?______

______

Medical Consent Form (Side Two)

I understand that it is my personal responsibility to provide for the expense of any medical or hospitalization that might be required by this participant. The First Baptist Church of Trussville (FBC) is excluded from financial obligations. I understand that my personal medical and hospitalization insurance available to my family will provide coverage. I agree to apply first for benefits from the personal hospitalization and medical coverage available to my family, if any, before applying for benefits that may be available from the First Baptist Church of Trussville's medical and hospitalization coverage.

I further understand that, in the event my child (or participant) requires medical or dental treatment while engaged in the activity of the FBC, reasonable efforts will be made to contact me; however, if I cannot be reached, I hereby consent and give permission to the FBC’s sponsor or any adult counselor acting on behalf of the FBC with respect to the activity, as agent for me, to consent to any x-ray examination; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child’s (or participant’s) medical allergies, medications being taken, medical problems and other pertinent information. My child (or participant) has permission to participate in all prescribed activities except as noted by me,

Date______/______/______Signature______

Insurance Carrier

Name of Insurance Company:______

Address:______

Name of Policy Holder:______

Policy Number:______Group/Member #:______

Phone Number of Insurance Company:_(______)______

Special Insurance Instructions: ______

Please notify the church office if any of the information contained in this form should change.

------Do Not Write Below This Line------

State of Alabama County of Jefferson

I, ______Notary Public, hereby certify that______,

whose signature appears on the foregoing conveyance, and who is know to me, acknowledged before on this day that, being informed the contents of conveyance, he/she executed the same voluntarily on the same bears date.

Given under my hand and notarial seal this ______day of ______

______

Notary Public