Name *

First Name

Last Name

Student's Phone

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Date of Birth *

MM

DD

YYYY

Parent/Guardian *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Emergency Contact *

First Name

Last Name

Additional Emergency Contact Phone *

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Release *

AUTHORIZATION FOR MEDICAL EMERGENCY TREATMENT TO: ANY PHYSICIAN, HOSPITAL, OR MEDICAL PERSONNEL This is to certify I give my permission for any ADULT SPONSOR or REPRESENTATIVE of the Martha Road Baptist Church of Altus, Oklahoma to secure emergency treatment, procedure, or medicine for my abovementioned child(ren) should this be deemed necessary. I also authorize church personnel to secure the use of an ambulance if necessary for transporting my child to the hospital. I further agree to pay the hospital, doctors, and ambulance for all services rendered to the above-named patient. Furthermore, unless sooner revoked or terminated by us, this Medical Release Form shall become NULL and VOID after December 31, 2021. I release the person(s) above and the Martha Road Baptist Church of Altus, Oklahoma from liability due to accident or injury. PHOTO/VIDEO RELEASE I understand my child will be photographed during camps, retreats, Bible studies, and other various events Martha Road Baptist Church, Altus, Oklahoma events and grant absolute right and permission for these photos or videos to be copyrighted, used, and published in material endorsed by Martha Road Baptist Church, Altus, Oklahoma and on the Martha Road Baptist Church, Altus, Oklahoma website.

I agree