Student Medical Waiver Form

Student Medical Waiver/Liability Form

ALL STUDENTS ARE REQUIRED TO FILL OUT A MEDICAL WAIVER FORM TO ATTEND ANY TRIP WITH CAMPBELLSVILLE BAPTIST CHURCH.

DATE

STUDENT INFO

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date

Grade

Phone

PARENT/GUARDIAN INFO

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

EMERGENCY CONTACT INFO

First Last

Phone

FAMILY PHYSICIAN INFO

First Last

Phone

INSURANCE COMPANY NAME

POLICY NUMBER

CHECK ALL THAT APPLY

ASTHMA

KIDNEY PROBLEMS

DIABETES

HEART PROBLEMS

FOOD ALLERGIES

DRUG ALLERGIES

INSECT BITES/STINGS ALLERGIES

OTHER ALLERGIES