2024 Adult Medical Form

Adult Name

Cell Phone

Address

Email Address

Emergency Contact Info

Emergency Contact

Emergency Contact Phone Number

This is the FIRST number we will try in the case of an emergency.

Emergency Contact Relationship to you

Health Information

Doctor's name

Doctor's Phone Number

Other Medical Conditions

Please list any pertinent health conditions that you may have.

Name and dosage of any medication that must be taken.

Date of last tetanus shot

Allergies

Yes No

If yes, please explain:

Any activity restrictions?

Yes No

If yes, please explain:

Health Insurance Information

Do you have health insurance?

Yes No

Health Insurance Company Name

Insurance Policy Number

Policy Holder's Name

Place of Employment

Liability Release

By agreeing to this form you agree to assume and accept all risks and hazaards inherent in church-related social activities. You also agree not to hold this church or its employees or volunteer assistants liable for damages, losses, or injuries to yourself or your property.

Yes, I have read the statement and agree.

Permission for Social Media

I grant Faith Bible Church permission to publish pictures of myself in FBC publications. No identifying information will be used.

Yes, I grant persmission. No, I do not grant permission.

E-signature

Date

Description

This form is for adult leaders involved in Faith Bible Church Student Ministries activities for the 2024 calendar year.

2024 Adult Medical Form

Description

Please Fix the Following