HTML Preview Medical Release Form Example page number 1.
Medical Release Form / Permission to Treat
Name
of
Church: First Baptist Church Kershaw
City/State: Kershaw, SC
Personal
Information:
Name:
SS
#
(optional):
DOB:
/
/
Age:
Gender:
Address:
City:
State:
Zip:
Emergency Contact
Information:
Parent/Guardian:
Home
Phone:
(
)
Work
Phone:
(
)
SecondaryContact:
Relationship:
Home
Phone:
(
)
Work
Phone:
(
)
Insurance
Information:
*Attach a copy of your insurance card to this
form.
Insurance
Co.:
Group#:
Policy#:
Cardholder:
Relationship
to
Cardholder:
Insurance
Co.
Address:
Insurance
Co.
Phone:
(
)
Personal Medical
Information:
Physician
s
Name:
Phone:
(
)
Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to
certain
meds, rare blood type, wears contact lenses,
etc.):