Medical Release Form
West Conroe Baptist Church Medical Release Form

Child's Name

Gender

Grade

Age

Address

City

Zip Code

Mother's Name

Mother's Home #

Mother's Work #

Mother's Cell #

Father's Name

Father's Home #

Father's Work #

Father's Cell #

Additional Emergency Contact

Please give name, phone # and relationship.

Additional Emergency Contact

Please give name, phone # and relationship

Please list any allergies your child may have.

(Medication, food, etc.)

Immunizations Current?

Date of Last Tetanus

List any significant health problems

Under a Doctor's Care?

Prescription Medication?

List any in box below.

Doctor's Name

Doctor's Phone #

Restriction of Physical Activity?

Insurance Carrier

Insurance Phone #

Insurance Policy #

Name of Insured

Electronic Signature