Permission/Medical Release Form
First Baptist Church
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
Date of Birth / Age:
In Case Of Emergency Notify
Your Relationship to the Above:
Policy No./Group No.
Policy Holder's Name
Name of Family Physician Phone
(See Reverse Side)