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Medical release

Prior to any trip or event, all students must have a current medical release form on file. Current medical release forms run from August-July of a school year. 

DOWNLOAD FORM OR FILL OUT BELOW

Student Name *
Student Name
Address *
Address
Home Phone
Home Phone
Cell Phone *
Cell Phone
Birth Date *
Birth Date
Physician's Phone Number *
Physician's Phone Number
Date of Last Tetanus Shot *
Date of Last Tetanus Shot
Father's Name *
Father's Name
Cell Phone *
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Address if different from above
Address if different from above
Mother's Name
Mother's Name
Cell Phone *
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Address if different from above
Address if different from above
I, the undersigned, do hereby release and forever discharge Gulf Breeze United Methodist Church (GBUMC) and sponsors from any and all claims, demands, actions or cause of action - past, present, and future - arising out of any damage or injury to my child whose name is listed above. My permission is granted to GBUMC staff member or GBUMC sponsor in charge to obtain medical attention in case of illness or injury to my child. *
Contact me about volunteering for Youth *

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First & Last Name *
First & Last Name
Cell Phone
Cell Phone