YM Medical Release

FIRST WAUGHTOWN BAPTIST CHURCH

Medical Release

First name

Last name

Birthday

Month

Day

Year

Medical Information (known allergies to food, drugs, insect stings or bites, etc.)

Special medical concerns or conditions that FWBC activity staff should know about, including epilepsy, asthma, diabetes, previous injuries to bone/joints, etc.

Family Physician

Name

Phone

Address

List special dietary needs

In the event of injury or illness to my son/daughter, I hereby authorize the FWBC activity representative to secure whatever treatment is deemed

necessary and if recommended by an attending physician, the administration of an anesthetic or surgery.

Parent/Guardian Signature

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Date

Month

Day

Year

Parent/Guardian Home number

Parent/Guardian Work number

Parent/Guardian Cell number

FIRST WAUGHTOWN BAPTIST CHURCH

Medical Release

Family Physician

838 Moravia St. | Winston-Salem, NC 27107 | 336.784.7386 © 2022 First Waughtown Baptist Church, Inc.

838 Moravia St. | Winston-Salem, NC 27107 | 336.784.7386
© 2022 First Waughtown Baptist Church, Inc.