Spreadsheet: 04960e69-04f5-4da4-b773-11201e8d2e94
Sheet: Sheet1

PERMISSION  AND  MEDICAL  CONSENT | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11
As parent or legal guardian, I hereby give permission for my child to participate in the following activity (the "Activity")
organized by |  | Columbus Avenue Baptist Church, Waco, Texas
Name of Activity
Child's Full Name
 |  |  | Last |  |  | First |  |  | Middle
Sex |  |  |  | Birthday |  |  |  | Age
Parent or Guardian Name
 | Home Address
 | Home Phone |  |  |  |  | Business Phone
If not available in an emergency, notify :
1. | Name |  |  |  |  | Phone  ( |  | )
 | Street Address
 | City |  |  |  |  | State |  |  | Zip
 | Street Address
 | City |  |  |  |  | State |  |  | Zip
Does this child have any allergies :
 | List here |  |  |  |  |  |  |  | Other :
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses,
which would have an effect on the child's participation in this Activity? |  |  |  |  |  |  |  | Yes |  | No
If yes, describe the problems or illnesses
State the name, address, medical specialty and phone number of this child's family physician and of any other
physician who should be consulted in the event of emergency or medical problems involving this child :
State the name, address, and phone number of this child's dentist (and orthodontist if applicable) :
Is there medical or hospitalization insurance which provides benefits for this child?  _______    If so, please indicate:
 | Name of Insurance Co.
 | Address
 | Policy No. of Insurance Policy
 | Name of Policy Holder
 | Phone No. of Insurance Co. |  |  | ( | )
Is  this  child on  any  medications? |  |  |  |  | If so, please state the medication :
If so, will this child be bringing to the Activity the medications that he/she should be taking?
I understand that Columbus Avenue Baptist Church |  |  |  |  | carries medical and  hospitalization  insurance
coverage which, consistent with the exclusions, limitations and terms thereof, may provide benefits over and above any
personal medical and hospitalization coverages available to my family.  I understand that any personal medical and
hospitalization insurance available to my family will provide primary coverage and the ministry's medical and
hospitalization coverage (subject to the exclusions, limitations and provisions in the ministry's policy) may provide
secondary or excess coverage.  I agree to apply first for benefits from the personal hospitalization and medical coverages
available to my family, if any, before applying for benefits that may be available from the ministry's medical and
hospitalization coverage.
I  further understand that, in the event my child requires medical or dental treatment while engaged in the Activity,
reasonable efforts will be made to contact me; however, if I cannot be reached, I hereby consent and give permission
to the ministry's sponsor or any adult counsellor acting on behalf of the ministry with respect to the Activity, as agent
for me, to consent to any X-ray examination; injections; anesthesia; medical, dental or surgical diagnosis and
treatment; and hospital care and treatment advised and supervised by a physician, surgeon, or dentist (as appropriate)
licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any
hospital.  To the best of my knowledge, I have listed above all of my child's medical allergies, medications being taken,
medical problems and other pertinent information.  My child has permission to participate in all prescribed activities
except as noted by me.
Signature |  |  |  |  |  |  |  | Date
 | (Parent or Guardian)
Print Full Name |  |  |  |  |  |  |  | Date
Copyright © 2003 by [NAME], CPA |  |  |  |  |  |  |  |  |  | Form 7-01.2
[NAME]
I hereby grant to Columbus Avenue Baptist Church the right to reproduce, use, exhibit, display, broadcast, distribute,
and create derivative works of church-related photographs or videotaped images of the undersigned individual for
use in connection with the activities of Columbus Avenue Baptist Church for promoting, publicizing, or explaining
the church or its ministry activities.  This grant included, without limitation, the right to publish such images in the
church's newsletter, worship guide, on the church's website, and advertisements, fund-raising materials, and any
other church-related publication.  These images may appear in any variety of formats and media now available to the
church and that may be available in the future, including but not limited to print, broadcast, videotape, CD-ROM, and
electronic/online media.
All photos taken are without compensation to me (the undersigned).  All electronic or non-electronic negatives,
positives, and prints are owned by Columbus Avenue Baptist Church.
I hereby acknowledge that I am 18 years of age or older and have read and understood the terms of this release.
Name (printed)
Signature