Registration Form

NAME_______________________ PHONE_______________________________
ADDRESS___________________________DATE OF BIRTH________________
CITY____________________STATE_________ZIP___________AGE_________

                                      MEDICAL HISTORY

HEART TROUBLE________ASTHMA__________SKIN TROUBLE_______
APPENDICITIS___________HERNIA__________LUNG TROUBLE_______
EAR TROUBLE__________MUMPS____________MEASLES___________
SCARLET FEAVER___________CHICKEN POX__________WHOOPING COUGH_____________ALLERGIES____________WHAT TYPE?______________
ANY OTHER MEDICAL PROBLEMS?___________________________________________________
ARE YOU ALLERGIC TO ANY MEDICATIONS?_______WHAT?___________


                                               IMMUNIZATIONS

(PLEASE GIVE YEAR)
WHOOPING COUGH__________TETANUS_____________POLIO_________
DIPTHERIA________________


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    LIABILITY AND MEDICAL RELEASE AUTHORIZATION FORM

(FOR CHILDREN UNDER 18)
I,_____________________________,PARENT OR GUARDIAN OF THE ABOVE NAMED CHILD, RELEASE FIRST BAPTIST CHURCH AND BEARING PRECIOUS SEED INTERNATIONAL OF ANY RESPONSIBILITY FOR INJURIES SUSTAINED DURING THE MISSIONS TRIP INTO MEXICO. IN CASE OF MEDICAL EMERGENCY, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY THE TOUR PERSONNEL TO HOSPITALIZE, SECURE PROPER TRATMENT AND ORDER INJECTION,ANESTHESIA OR SURGERY FOR MY CHILD AS SEEMS NECESSARY AND IN ACCORDANCE WITH THE MEDICAL HISTORY AS STATED ABOVE.

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                                                             PARENT OR GUARDIAN        DATE

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(FOR ADULTS)
i RELEASE FIRST BAPTIST CHURCH AND BEARING PRECIOUS SEED PERSONNEL OF ANY RESPONSIBILITY SUSTAINED DURING THE MISSION TRIP. IN CASE OF MEDICAL EMERGENCY, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY THE TOUR PERSONNEL TO HOSPITALIZE, SECURE PROPER TREATMENT AND ORDER INJECTION, ANESTHESIA OR SURGERY FOR ME AS SEEMS NECESARY AND IN ACCORDANCE WITH THE MEDICAL HISTORY AS STATED ABOVE.
   

                                                              
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                                                                  NAME                                      DATE











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AFFIDAVIT