Please fill this form out in its entirety. Do not leave any blank spaces.

    Gender
    MaleFemale

    T-Shirt Size
    SmallMediumLargeXLXXLXXXL

    PARENT / GUARDIAN INFORMATION

    Another Emergency Name and Number other than parents.

    INSURANCE COMPANY: PROVIDE A PHOTO COPY OF BOTH SIDES OF YOUR INSURANCE CARD.

    No InsuranceSelf Insured

    MEDICAL HISTORY

    (Please check all that apply and provide appropriate information)

    AsthmaUlcersSinusitisKidney TroubleBronchitisHeart TroubleDiabetesDizzinessOther (List below)

    Previous operation or illness:

    Date of last Tetanus shot:

    Any current special medications:

    Name and Number of Physician:

    ALLERGIES

    Food:

    Penicillin/Other Drugs:

    Insect Stings or Bites:

    Poison Sumac, Ivy, Oak:

    Parental Consent

    My permission is granted for Riverview Baptist Church, staff, sponsors, or chaperones in charge to obtain necessary medical attention in case of sickness, injury, or accident to my child, and that any expenses incurred are my responsibility. Riverview Baptist Church will not be held liable for the loss of money or other personal items that may be lost or missing. Any damages or losses caused by my child, individually or with a group shall become my responsibility.

    Use of any tobacco products, intoxicating beverages and/or drugs shall be prohibited. Other rules that are established to ensure proper health, safety, and enjoyment for all concerned shall be enforced. Failure to cooperate within these standards will result in my child being sent home early, and I; him/her; and he/she understands both the expectations and the consequences for failure to meet those expectations.
    I, the undersigned, do hereby verify that the above information is correct, and I do hereby release and forever discharge all staff, members, in an organized activity of Riverview Baptist Church.

    I agree.

    Signed (Parent/Guardian)

    dated this day of , 2020 Tulsa County, Oklahoma