Fun Friday Child Information Form, Medical Release and Transportation Waiver

Child Information Form

Child’s Name _____________________________________________ Age ________ Birthdate ______________________

Family Address _________________________________________________________________________________________

Home Phone ( ) ________________________________

Mother’s Name ___________________________________________ Cell Phone ( )_______ Work phone ( ) _____________

Father’s Name ___________________________________________ Cell Phone ( )_______ Work phone ( ) _____________

Guardian’s Name _________________________________________ Cell Phone ( )_______ Work phone ( ) _____________

Allergies to Drugs or Food _____________________________________________________________________________________

Pertinent Medical Information __________________________________________________________________________________

Hospital Insurance: Yes ____ No ____ Date of last Tetanus inoculation _______________________________________

Insurance Company ______________________________________________________________________________________________

Policy # _______________________________________________________________________________________________________

Family Physician _____________________________________________ Office phone ( ) ______________________________

Office Address _________________________________________________________________________________________________

What would it be important for us to know in order to care for your child well?

Transportation Waiver/Emergency Medical Authorization
Prairie Baptist Church

I give my consent for my minor child _____________________________________ to be transported by approved drivers for Prairie Baptist Church for the following events:

June 13 — Federal Reserve Bank Money Museum, 1 Memorial Drive, Kansas City, MO
June 20 — Society of St. Andrew, Gleaning Project, farm site location TBA
June 27 — Shawnee Mission Park Beach, 7900 Renner Road, Shawnee, KS
July 11 — Harvesters Distribution Center, 3801 Topping, Kansas City, MO
July 18 — Creative Carnivals and Events, 11171 W. 87th Terrace, Overland Park, KS

In the event of an emergency, I hereby give permission to the Prairie Baptist Church appointed sponsors to obtain medical assistance for my minor child, _________________________________. I also give permission to the physician selected to hospitalize and secure proper treatment for the above-named person.

In addition, I waive Prairie Baptist Church and their respective volunteers and staff of any legal responsibility in case of illness or injury to the above-named person.

Date __________________

Child’s Name _________________________ Age ___________ Birthdate _________

Parent/Guardian Signature _____________________________________________

Home Phone Number ________________ Work Phone Number ______________

Allergies to Drugs or Food _____________________________________________

Pertinent Medical Information __________________________________________

Hospital Insurance: Yes ___ No ___ Date of last Tetanus inoculation _________

Insurance Company _____________________________________________________________

Policy Number______________________________________________________

Physician’s Name _______________________________________________________________

Physician’s Phone Number _______________________________________________________

If I cannot be reached, please notify: ______________________________________

(_____)_________________ Relationship ______________

Medical Release Form for Prairie Baptist Church

In the case of a medical emergency, we (I) hereby authorize the staff, teachers, and children’s leaders of Prairie Baptist Church to obtain the services and give consent for any and all necessary emergency medical care for my child ______________________ (first and last name) while she/he is a participant in the children’s programming at Prairie Baptist Church between the dates of June 1, 2014 and May 31, 2015. Please notify us (me) immediately concerning any such emergency. We (I) understand that we (I) will be liable for all costs and expenses incurred in case of such an emergency.

Mother’s signature __________________________________ Date ______________

Father’s signature __________________________________ Date ______________

Legal Guardians’ signature ____________________________ Date ______________

Emergency contact person and number: ( ) _______________________________

__________________________________________________________________________________________________________________________________________________________________

Notarization of Signature

County and State Johnson County, Kansas

Signed or attested before me on ______________________ by ____________________________

Seal or Stamp:

Notarized by ________________________________________________

My Appointment Expires: ______________________________________