Medical & Liability Form

Student Name *
First Name
Middle
Last Name
Parent/Guardian Name *
First Name
Middle
Last Name
Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Student Email*
Student Cell Phone #*
Parent/Guardian Email*
Parent/Guardian Cell Phone #*
Check All That Apply *
Food Allergies*
Drug Allergies*
Insect Bites/Sting Allergies*
Other Allergies*
List Medications*
Permission for Treatment My permission is granted for Campbellsville Baptist Church staff to obtain necessary medical attention in case of sickness or injury to my child. Also, I understand that as a participant my child may be photographed or videotaped during normal CBC activities and these photos / Video may be used in promotional materials. I, the undersigned, do hereby verify that the above information is correct and I do hereby release whatever discharge Campbellsville Baptist Church and all its staff, board members, and chaperones from any and all claims, demands, actions, or cause of action, past, present, or future arising out of any damage or injury while participating with our church on an outing or an event.
By putting your name here you are agreeing to the permissions listed above and stating that everything is correct.*
By putting your name here you are agreeing to the permissions listed above and stating that everything is correct.*
Today's Date*
*