Virginia Medical Release Form 1 - Free Download
This form is provided by the First Baptist Church for the medical information release regarding the medical care and treatment necessary to be administered.
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Virginia Medical Release Form 1
Virginia Medical Release Form 1
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)
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