Name

First Name

Last Name

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Grade

Medical Insurance

Primary Care Physician

Primary Care Physician's Phone

(###)

###

####

Allergies

Medications

Parent's Name

Parent's Phone

(###)

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Permission and Release to Treat

In case of emergency, you are authorized to take such measures necessary and arrange for such medical and hospital treatment, as you may deem necessary for the health and well being of my child. I release Salem Heights Baptist Church, the staff and volunteers from any claim or any liability due to sickness or injury to my child. I authorize and release Salem Heights Baptist Church, the staff and volunteers to speak to my child's Primary Care Physician, as they deem necessary, and I wave any claim of medical privilege.

In consideration for my child being allowed to participate in activities by Salem Heights Baptist Church, I hereby release, discharge, indemnify, and agree to hold harmless Salem Heights Baptist Church, its directors, officers, employees, and all volunteer personnel from any and all liability for personal injuries and/or damage(s), injury or illness that may be suffered by _______________________________________ I also agree to pay for any damages to persons or property for which my child may be responsible. I further agree to indemnify and hold harmless Salem Heights Baptist Church, its directors, officers, employees, agents and all volunteers for any claim and/or damages it or its agents are required to pay or incur as a result of any injury or damage including reasonable attorney fees, litigation expenses, and court costs.

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Phone Number:
(601) 763-7571

Fax Number:
(601) 763-7729

Physical Address:
5850 Highway 84 West
Laurel, MS 39443

Mailing Address:
P.O. Box 2758
Laurel, MS 39442

Email:
mkwright629@gmail.com

© SALEM HEIGHTS BAPTIST CHURCH 2022

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Phone Number:(601) 763-7571

Fax Number:(601) 763-7729

Physical Address:5850 Highway 84 WestLaurel, MS 39443

Mailing Address:P.O. Box 2758Laurel, MS 39442

Email:mkwright629@gmail.com

Phone Number:
(601) 763-7571

Fax Number:
(601) 763-7729

Physical Address:
5850 Highway 84 West
Laurel, MS 39443

Mailing Address:
P.O. Box 2758
Laurel, MS 39442

Email:
mkwright629@gmail.com