MRBC Medical Release and Permission Form 2026

Child's Name

Age

Current/Last Completed Grade

Child's Date of Birth

Address

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

This address will receive a confirmation email

Which of the following best describes your child?

Good Swimmer Fair Swimmer Non Swimmer Other

Does your child have any allergies?

Please list the date of the child's last tetanus shot.

Does your child suffer from or is being treated currently for any of the following?

Asthma Epilepsy/Seizures Heart Trouble Diabetes Chronic Stomach Issues Physical Handicap None

Does your child wear corrective eye-wear?

Yes No

Should your child's activities be restricted for any reason?

No possession or use of alcohol, drugs, tobacco, electronic cigarettes, or look-a-like substances; no fighting, weapons, fireworks, lighters, or explosives of any kind; no males in female sleeping quarters; no females in male sleeping quarters; respect the property of others; respect your fellow students, staff, and adult leaders; respect and comply with event activities and schedules; no offensive or immodest clothing; shirt straps should be at least 3 finger inches wide; skirts should not be higher than 3 inches above the knee when standing (no mini-skirts); shorts are too short when you can touch skin when your arms are straight down; shirts are too short if the abdomen is exposed; no tight or revealing clothing; pants should be kept pulled up around the waist; swim suits should be modest, one-piece for females; males must wear shorts; no speedos. Students who fail to comply with these expectations may be sent home at their parent/guardian's expense.

My child and I have reviewed the code of conduct and dress expectations. We agree to abide by these expectations.

My child has my permission to attend all activities sponsored by Miles Road Baptist Church. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Miles Road Baptist Church and its staff of any liability against personal losses of the named child. Note: if you desire to limit your child's participation in any future activities and events, you must submit your wishes in writing to the church Youth Minister or Director of Children's Ministry.

I agree

I the undersigned have legal custody of the student named above, a minor, and have given consent for him/her to attend events being organized by Miles Road Baptist Church. I understand that there are inherent risks involved in these activities and hereby release the church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child's involvement. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Miles Road Baptist Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. I also agree to bring my child home at my expense should he/she become ill or if deemed necessary by a student ministries staff member.

I agree

Signature Required (Please type name)

MRBC Medical Release and Permission Form 2026

Description

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