Chapel Wood Baptist Church/ Camp Creation
30410 Maple Valley-Black Diamond Rd
Black Diamond, WA 98010 (425-830-5947)

Child Information

Name__________________________________ Birth date________ Grade_____
Daytime Phone # (____)______________________ (to reach parent)
Address___________________________________ City______________ State_____ Zip___________
Evening Phone # (____)______________________

Additional Contact #(____)___________________ Daytime Number

Authorization of Consent to Treatment of Minor: (I))(We), the undersigned, parent(s) of _______________, a minor,
do hereby authorize Chapel Wood Baptist Church children ministry leaders as agent(s) for the undersigned to consent to any x-ray examination,
anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general
or specific supervision of, any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or
treatment is rendered at the office of said physician or at a hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment,
or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s)
to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician
in the exercise of his best judgment may deem advisable.

Parent (signature)___________________________________


Release of the Chapel Wood Baptist Church:

___________________ (parent's name) shall indemnify, hold free and harmless, assume liability for, and defend the Chapel Wood Baptist Church
and its agents, servants, employees, officers, and directors from any other sums which the Chapel Wood Baptist Church, assertion of liability,
or any claim or action founded thereon, arising or alleged to have arisen out of ___________________ (child's name) use of real or personal
property belonging to the Chapel Wood Baptist Church and its affiliate corporations, its agents, servants, employees, officers, and directors,
or action or omission by___________ (child's name). I give permission for CWBC to use any photos of my child in their publications: and I release
my right to any kind of compensation.

Day Phone (_____)_____________ Cell (_____)________________ Evening (_____)_______________

Parents/Guardian Email Address________________________________________________________

Other Emergency Contact________________________    Phone (_____)_______________________

Family Doctor____________________________________    Phone (_____)_______________________

Insurance Co.____________________________________    If not insured please check here ____

Policy #, or Group # ____________________________________________________________________

Known Medical Conditions______________________________________________________________



Last Tetanus Immunization?_________________________   Contact Lenses?__________________

Will Allow Blood Transfusions? (Check) YES______ NO_______


Parent (signature)___________________________________


Legal Guardian____________________________________________ Date________________________