MEDICAL RELEASE FORM
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List any and all medical conditions/allergies (food, drug) that we need to be aware of and any medications you are currently taking (including prescriptions)

I, hereby give permission for the above mentioned student to attend the above listed event with Immanuel Baptist Church Student Ministry. I understand that my own insurance will cover any accidental injury or illness involving my student and that I will be responsible for any expenses incurred. I release Immanuel Baptist Church, its agents, employees, and volunteers from any and all liability for accidents, injury or illness, which occur. I also authorize the sponsors of this trip to authorize emergency medical treatment for my student.

SIGNATURE OF PARENT/LEGAL GUARDIAN:

Emergency Contact Information

P.O. Box 212 315 WEST Immanuel st. Nashville, AR 71852
(870)845-3414