VBS MEDICAL RELEASE FORM

I/We, the parent/s of ____________________________________(child’s name), do hereby grant to Pastor Bill Myers, Pastor to Young Families at Twin Oaks Presbyterian Church, the right and authority to make medical decisions and to obtain medical treatment for the aforesaid child in the event that an emergency medical situation arises while my child is on the premises of Twin Oaks Presbyterian Church. The undersigned agrees to hold harmless, and by signing below, fully releases Pastor Bill Myers, Twin Oaks Presbyterian Church Corporation, any of their affiliates and any affiliated persons chargeable with any supervisory or any other responsibility or liability, relating to emergency medical treatment. I/We, the parents, agree that whether a situation is categorized or defined as a medical emergency shall be at the discretion of Pastor Bill Myers. I/We, the parent/s, agree to be responsible for any emergency medical costs involved.

Please provide Medical Insurance information here:

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Insurance Policy Name and Group Number:

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List any allergies or medical conditions which we should be aware of in case of emergency.

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Parent(s) Signature(s): Only one signature required:

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