Medical Authorization Form

First Baptist Church, Naples

Student’s Name:___________________________________________
Circle student’s shirt size:
ADULT SIZE: S M L XL XXL YOUTH SIZE: M L
Address:_________________________________________________
City/State/Zip:_____________________ Home Phone:____________
Birth Date: ________________________ Current Age: _____
Grade: ________ Circle One: Male Female
Mother: ____________ Father:__________Guardian:_____________
Work Phone:_______________ Cell: ___________ Pager: _________
If parent/guardian cannot be reached in an emergency, call:
Name: ___________________________Phone: _________________

HEALTH INSURANCE INFORMATION:

Carrier___________________Policy No.________________________
Phone___________________________

FAMILY PHYSCIAN:________________ Phone:____________________

Allergies (Drugs, Food, Insects, Etc.):__________________________

CURRENT MEDICATIONS:__________________________________
Immunizations:
Tetanus:_______________ Date of Booster:_______________
Other:__________________

PREVIOUS ILLNESSES: (CHECK AND GIVE DATE TO ALL THAT APPLY)

Appendicitis:___________ Heart:___________ Diabetes:__________
Rheumatic Fever:________ Convulsions:_________ Other:_________

I hereby authorize any adult youth worker acting as an agent for First Baptist Church, Naples
to be the Limited Guardian for __________________, my minor child, on any church related
trips. This Limited Guardianship is for the specific purpose of procuring medical attention for
my minor child in emergency situations. This authorizes the above named because of the
nature of the emergency, there is not time to contact me or any other natural guardian of the
child. I further authorize the above named person to do any of the acts without permission or
other order of any court and without specific bonds unless mandatory by law. In consideration
of the possible injuries, which could occur in this event, I hereby release all participating
groups and persons officially connected with this event from any and all liability for any injury
or damages whatsoever arising from any participation in this event.

________________________________________________________
(Signature) (Date)

State of Florida, County of Collier

Personally appeared before me, the undersigned authority a Notary Public, in and for
said state and county, the within-named party, ___________________, who
acknowledged the within instrument for the purpose therein contained.
Form of ID: Personally known ___________Drivers License________ Other _______
Witness my hand and official seal this ________ day of_____________ 20______.

_____________________________(Notary Public)