2025 Calvary ADULT Annual
Emergency Medical Release Form

This form is valid from January 1 through December 31, 2025.

Personal Information

First Name

Last Name

Birthdate

Gender

Last 4 digits of SSN:

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Emergency Contact Information

Primary Contact - First Name

Last Name

Phone Number

Work Phone

Relationship:

Secondary Contact - First Name

Last Name

Phone Number

Work Phone Number

Relationship:

Personal Medical Information

Specify N/A in the fields below that do not apply.

Physician's Name:

Physician's Phone:

Allergies

Personal Physical Limitations (asthma, diabetes, etc.), and/or special instructions (rare blood type, wears contact lenses, etc.):

List ALL medication taken on a regular basis and/or any you will take to an event. (Prescription meds MUST have a pharmacy label and name of doctor.)

List all operations/serious injuries and dates within the past five (5) years:

Date of the last tetanus shot:

Insurance Information

*Please submit a copy of your insurance card.

Insurance Company

Insurance Company Address

Insurance Company Phone

Group #

Policy #

Cardholder - First & Last Name

Relationship to Cardholder

Consent and Release

I , do hereby give authority to any adult over 21 years of age who represents Calvary Baptist Church on a trip or retreat with Calvary Baptist Church to approve any medical or first aid treatment I need in the event of emergency due to sickness or accident while I am with the church activity. Any treatment would be with my full consent. This consent and release will be in effect for the entire year. I understand that Calvary Baptist Church or its representatives on this trip will not be held responsible for any accident or sickness while participating in Calvary Baptist Church events.

Photography Consent

Select one:

I do NOT give consent for my photo to be publicized.

I give permission for my photo to be taken for church-use.

Publications may include the church website, newsletter, and social media.
We will never include your child's name with the publicized image.

Signature

Today's Date

Please provide a copy of your insurance card (FRONT and BACK)

I will bring to the church office during office hours M–F.

I will email a copy to kedwards@calvarytupelo.com.

2025 Calvary ADULT AnnualEmergency Medical Release Form

Personal Information

Emergency Contact Information

Personal Medical Information

Insurance Information

Consent and Release

Photography Consent

2025 Calvary ADULT Annual
Emergency Medical Release Form