Download Virginia Medical Release Form for Free

The Virginia Medical Release Form is a template which is under the law of Virginia State. This template is pretty simple and clear, which consists of several main parts, namely, the necessary information and statement of the concerned person, In Case of Emergency Notify, Insurance Information, Allergies, Restrictions, Medical History, Medication and the signatures. If this template can give you some reference, you can visit our website to download.

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Permission/Medical Release Form
First Baptist Church
Waynesboro, Virginia
I ,___________________________, understand and agree that during travel with the First Baptist Church of
Waynesboro, Virginia, on all events for _______ (year), that these are the procedures that are followed.
In the case of an emergency while the named individual is in the care of First Baptist Church, the church will
notify the emergency persons listed below immediately. In the event the church is unable to reach these persons
immediately, the church party responsible and or its' designated staff is authorized to seek and obtain medical attention,
treatment, and services as may be deemed necessary. I agree to assume responsibility for payment of all medical costs
incurred.
Full Name:
________________________________________________________________________
Address:
_____________________________________________
City:
__________________________
State:
__________________
Zip Code:
________
Home Phone:
______________________________
Work Phone:____________
____________________
SSN:
____________________________
Date of Birth / Age:
_____________/______
In Case Of Emergency Notify
1.Name
_____________________________________
Hm Phone
______________
Work
_____________
2.Name
_____________________________________
Hm Phone
______________
Work
_____________
Your Relationship to the Above:
1.
_____________________________________
2.
______________________________________
Insurance Information
______________________________________________________________________________
Company Name
______________________________________________________________________________
Policy No./Group No.
______________________________________________________________________________
Policy Holder's Name
______________________________________________________________________________
Name of Family Physician Phone
(See Reverse Side)
Virginia Medical Release Form
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