1. 2010 ANNUAL CONSENT/RELEASE FORM
Wyomina Park Baptist Church
1411 NE 14th Street
Ocala, FL 34470
NAME: ______________________________AGE:____BIRTHDATE:________SS#:_______________
ADDRESS: ____________________________________CITY/ST/ZIP: _________________________
EMERGENCY CONTACT: ___________________________________HOME PHONE: _______________
CELL PHONE: ________________
INSURANCE CO: _______________________________________POLICY #:____________________
INS. CO. PHONE #:_______________________PHYSICIAN:_________________________________
MEMBER’S NAME: _________________________________ Member’s Birth date: ________________
ALLERGIES: _______________________________________________________________________
MEDICATIONS: ____________________________________________________________________
EMERGENCY NAME & NUMBER OTHER THAN PARENTS:
NAME: ________________________________________________PHONE #:___________________
I am the parent and/or legal guardian of ________________________________________ and hereby acknowledge that he/she
is under my care, custody, and control. In the event there arises an emergency requiring medical attention, I expressly grant
my permission and consent to the Wyomina Park Baptist Church (hereafter WPBC) staff, its representatives, sponsors, and/or
any attending physician, to make such decisions and to perform any medical or surgical treatment upon my child listed above,
which may be in their sole discretion to be necessary and proper under the circumstances. I, the undersigned parent and/or
legal guardian of the above mentioned child, do release, acquit, discharge, and convent to hold WPBC or its representatives,
sponsors, or any attending physician, from any and all actions, causes of actions, related risks and dangers, including
negligence, damages, liabilities, arising out of the treatment of any sickness or accident, and my financial responsibility for all
medical treatment provided. I also assume financial responsibility for any damages my child may cause, and for providing
transportation home should it become necessary for disciplinary reasons. I also give my permission to the WPBC staff, its
representatives, sponsors, and the adult chaperones to search my child’s personal belongings, including but not limited to
luggage, purses, and backpacks, if deemed necessary on rare occasions for security reasons. I hereby give my permission for
my child to participate in the events/activities, and ride in contracted transportation and/or privately owned vehicles with WPBC
adult leaders/chaperones. I further agree to hold WPBC and/or the private vehicle owner, harmless from any liability related to
physical injury, personal property damage and/or other condition as a result in my child’s participation. I hereby give my
permission for my child’s picture from our Student Ministry events to be placed on the WPBC Youth Group website. First names
only will be used on the website. I have instructed my child to obey the Student Ministry leadership at all times. This Consent/
Release is valid for the year 2010 and is valid for all WPBC Student Ministry events/activities. It is the sole responsibility of the
Parent/Legal Guardian to notify the WPBC Student Ministry of any changes in the information provided above. (MUST BE
SIGNED IN THE PRESENCE OF A NOTARY PUBLIC)
________________________________________ _____________________________________ __________________
Printed Name of Parent/Guardian Signature of Parent/Guardian Date
STATE OF FLORIDA, COUNTY OF MARION
The foregoing instrument was acknowledged before me this __________ day of ______________________________, 2010, by
________________________________________, ___Personally known or
___Produced Identification (Type: _____________________)
_____________________________________
Notary Public for Florida