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HEALTH RECORD, CONSENT FOR TREATMENT, AND RELEASE

Note: Participant - It is important that you complete the following Health Record. Copies of this paperwork will be maintained in the Church office and taken on in-town, overnight and out of town trips.

Annual Liability Release Form
Release of All Claims - Adult Participants

In consideration of being accepted by First Baptist Church of Fairhope, Alabama Inc. for participation in all church activities, events or trips to be held during the next year, (I), being 19 years of age or older do hereby release, forever discharge and agree to hold harmless First Baptist Church of Fairhope, Alabama Inc., its staff, employees, leaders, directors, volunteers and any other agents (hereinafter called “agents”) from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned that occur while participating in any church activity, event or trip, regardless of the location(s) of such activity, event or trip.

Assumption of Risk

Furthermore, we (I) assume all risk of personal injury, sickness, death, damage and expense as a result of participation in all aspects of the above referenced activity/event for ourselves and on behalf of the child participant. Such risks may include exposure to other participants who are ill or have special medical conditions.

Indemnification

The undersigned agrees to hold harmless and indemnify First Baptist Church of Fairhope, Alabama Inc. and its agents for any liability and related expenses sustained by said Church as the result of the negligent, willful or intentional acts of said participant.

Medical Treatment Authorization

Permission is granted to take said participant to a doctor of hospital if needed. We (I) authorize medical treatment, including but not limited to emergencey surgery, and assume the responsibility of all medical bills, if any.

Unplanned Transportation Costs

Further, should it be necessary for the participant to return home due to medical reasons, we (I) assume all transportation costs and as appropriate, to fully indemnify and /or reimburse First Baptist Church of Fairhope, Alabama Inc. or its agents.

Photo/Audio/Web Release

Further, we (I) consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the participant during their participation in any activity, event or trip to be used, distributed, or shown as said Church sees fit including but not limited to: slide shows, church website, print media and local newspapers.

Today's date: July 26, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

In case of emergency, list in order of preference to whom contact should be made 


Name

Relationship

Phone Number

Address

Name

Relationship

Phone Number

Address
Insurance Information

Name of Insurance Co.

Address

Policy No. of Insurance Policy

Name of Policy Holder

Phone No. of Insurance Co.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Medical History


List your allergies (drugs,& environment):

Are you taking any medications or are on any special diet or exercise restrictions? If yes, please list specific details.

List the medications you currently take (name of drug, dosage,etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)

Previous Surgeries or serious illness:
Have you had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough

State the name, address, medical specialty and phone number of your family physician and of any other physician who should be consulted in the event of emergency or medical problems involving applicant
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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