RELEASE AND CONSENT TO MEDICAL TREATMENT

STATE OF TEXAS

COUNTY OF COLLIN

I do hereby consent as parent or legal guardian of ________________________________to reasonable and necessary medical treatment in the event of the necessity therefore, and I hereby authorize the First Baptist Church of McKinney, through its employees, agents and volunteers, to provide such consent to any health care provider that may require it, sign necessary papers, and in general arrange for reasonable and necessary medical care and treatment that may be necessary.

            I further release and forever discharge the First Baptist Church of McKinney, its employees, agents and volunteers of and from any and all claims, demands, damages, actions, causes of action, negligence or suits of any kind or nature, whether heretofore or hereafter accruing, and whether not known, arising out of any activity of the First Baptist Church of McKinney in which my child is a participant.

            This Release and Consent shall be valid and binding until revoked by me, in writing, delivered to Grant Byrd, First Baptist Church of McKinney, Texas.  I acknowledge that I have read and understand the effect of this Release and Consent to Medical Treatment, and I am executing it for the purposes and considerations set forth.

_______________________________

Parent or Guardian

Dated this __________ day of _______________, 2008.

Insurance Information:

Carrier: ________________________________________________

Group Number: _________________________________________

Policy Number: _________________________________________

Telephone number of Insurance Company: ___________________

Xtreme Camp 2008

Contact Form

Name:

Last _______________________       First _______________  Middle ___________

Age: ____                  Date of Birth  ________________ 

Male  ___       Female  ___      

Address:  _________________________________________________________                   City _______________________________       St. ______                 Zip ____________

Parent or Guardian Name: ______________________­________________________

Phone:              Home  ________________   cell ___________________     

                              Work  _________________

Email ___________________________________________________________

Any special requirements or attention needed:

_______________________________________________________________

Health related information:_____________________________________________

_______________________________________________________________

Dietary restrictions:__________________________________________________

_______________________________________________________________

Current medication (send with instructions): _______________________________________________________________

Reason for taking above medication: ______________________________________

_______________________________________________________________