Medical Release Form

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The information from this form will be used in the signing of your document(s). Once you've filled out and verified the applicable information below, you'll have a chance to review your documents prior to signing.

First Name

Middle Name

Last Name

Phone

Date of Birth

Please email important updates from First Baptist Church Niceville

Are you a member of FBCN?

Yes

If you're not a member of FBCN, where do you attend church?

Please list your medical insurance company name and policy number.

Please list your Doctor's name and phone number.

Do you have allergies?

Yes

Are you Allergic to Insect Stings/Bites?

Yes

Do you take any drugs?

Yes

Please explain any of the above or below as well as your health history.

Please chek any of the following that pertain to you.

Heart Condition

Hay Fever

Frequent Stomach Upsets

Epilepsy

Chronic Asthma

Frequent Colds

Physical Handicap

Date of last Tetanus shot:

Name and dosage of any medications that must be taken.

Do you have any swimming restrictions?

Yes

Do you have any activity restrictions?

Yes

Please explain any restrictions you may have.

Please list your emergency contact name and phone number.

Please list your Alternate Emergency Contact (other than parent).

Please check the medications that FBCN is authorized to administer if needed.

Acetaminophen (Tylenol)

First Aid Ointment/Gel

Antibiotic Ointment (Neosporin)

Antacid Tablet (Rolaids/Tums)

Ibuprofin (Advil)

Benadryl

This form and process is powered by Wix on behalf of First Baptist Church Niceville. First Baptist Church Niceville will collect and use your data in accordance with their Privacy Policy and/or Terms of Service. Please direct any questions about their Privacy Policy and/or Terms of Service or the use and collection of your data to steve@churchonbayshore.org

Church
on

Bayshore

850.678.4621
connect@churchonbayshore.org

622 Bayshore Dr.
Niceville, FL 32578

Office Hours
Monday - Thursday 8:30AM - 4:30PM

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