Medical & Surgical Waiver

Minor (18 & under) 2021

I, the parent and/or guardian of the above listed student, who is a minor, hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give the said minor my express permission to travel to/participate in church-sponsored events and functions of Green Acres Baptist Church from January 1, 2021, through December 31, 2021. In the event there arises an emergency necessitating emergency medical or surgical attention, I hereby consent and give permission to Green Acres Baptist Church, or its representatives, and/or any attending physician to make such decisions and to perform such medical or surgical treatment upon said minor, which in their sole discretion, may be reasonable and necessary under the circumstances.

I, the undersigned parent and/or guardian of said minor, do release, acquit, discharge, and covenant to hold harmless the said Green Acres Baptist Church or its representatives from any and all actions, damages, and/or liabilities arising out of the treatment of any sickness or accident incurred by said minor. It is the intention of this release that Green Acres Baptist Church and its representatives incur no liability whatsoever while attending to the reasonable and necessary treatments, surgery, and other medical needs that may, in their sole discretion, be needed by said minor.

I, the undersigned parent and/or guardian of said minor, give permission to include my student in Green Acres Baptist Church pictures, videos, and/or other media.
Parent/Guardian Signature *
Student Signature *

Health Form

Birthdate *
** It is your responsibility to complete a MEDICATION DISPENSE FORM and turn in with any medications before the trip **

Medical Insurance

Policy Holder DOB