RIVERSIDE STUDENT MINISTRY Medical Release Form

You can download the form below to fill out and return to the Student Pastor or fill out the online form below.

PERMISSION & MEDICAL RELEASE FORM
Authorization to Consent to Treatment of a Minor and Release of Liability

THIS FORM IS GOOD FROM THE DATE SUBMITTED

I, the undersigned parent/legal guardian of (Student's Name provided below) minor(s), understand that in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I do hereby authorize Riverside Baptist Church as an agent for the undersigned to consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provisions of the PHYSICIANS AND SURGEONS ACT and on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or said hospital. It is understood that this authorization is given in advance of any specific need for authorization of consent as outlined above. I hereby release the staff, volunteers and Riverside Baptist Church of any legal responsibility if my child becomes ill or injured in any way. I have read the above and consent to my child’s (children’s) participation in the activities of this ministry. I also understand that my child is subject to the authority of the church’s designated leaders. Any failure to comply with leadership could mean the loss of privilege in participating in an activity.

Student's Name *
Student's Name
Parent's Name *
Parent's Name
Address *
Address
Home Phone *
Home Phone
Parent's Emergency Contact Name *
Parent's Emergency Contact Name
Parent's Emergency Contact Phone# *
Parent's Emergency Contact Phone#
Parent's Emergency Contact Name2 *
Parent's Emergency Contact Name2
Parent's Emergency Contact Phone#2 *
Parent's Emergency Contact Phone#2
Family Doctor Name *
Family Doctor Name
Family Doctor Phone# *
Family Doctor Phone#

RIVERSIDE STUDENT MINISTRY IS THE STUDENT MINISTRY OF RIVERSIDE CHURCH, sbc.
2401 Alcott Street, Denver, CO  80211  Phone: (303)433.8665
Landis Elder, Pastor of Student Ministries    
email: lelder@riversidedenver.com