Kid's/Student's Name (required)

Kid's/Student's Age (required)
years

Parent/Guardian's Name (First & Last)

Parent/Guardian's Email Address

Medical concerns, special needs or food allergies

EMERGENCY CONTACT (parent/guardian preferred)
Name

Phone

MEDICAL RELEASE

As a parent and/or guardian, I do herewith authorize treatment under the direction of any licensed physician of the minor(s) registered above in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life or cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

The undersigned assumes the responsibility for any cost connected with such treatment. I hereby agree to release Southside Baptist Church and its staff and volunteers from liability in the event of injury.

A copy of this authorization can be used as the original.

Medical Insurance Provider

Medical Insurance ID

Upload images of medical insurance card:
Front of Card:
Back of Card:

By checking this box, you verify that this form is completed and submitted of your free will with the sole purpose of authorizing medical treatment under emergency circumstances in your absence.

Type the code you see in the box below.

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