Name of MOM:
Name of DAD:
Mom Work Phone
Mom Cell Phone
Dad Work Phone
Dad Cell Phone
No InsuranceSelf Insured
AsthmaUlcersSinusitisKidney TroubleBronchitisHeart TroubleDiabetesDizzinessOther (List below)
Previous operation or illness:
Date of last Tetanus shot:
Any current special medications:
Insect Stings or Bites:
Poison Sumac, Ivy, Oak:
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.
dated this day of , 2020 Tulsa County, Oklahoma