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SEC Release Form
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»
SEC Release Form
2024 SEC Medical and Liability Release Form
Step
1
of
4
25%
Emergency Contact Information
Student Name
(Required)
First
Last
Contact Name
(Required)
First
Last
Contact Relationship
(Required)
Contact Phone
Contact Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Church You Are Attending With
(Required)
T-shirt Size
(Required)
Backup Contact Information
Backup Name
(Required)
First
Last
Backup Relationship
(Required)
Backup Phone
(Required)
Health Information
Student Health History
(Required)
Bleeding/Clotting Disorders
Chicken Pox
Convulsions
Diabetes
Frequent Ear Infections
Hearing Defect/Disease
Hepatitis
Hypertension
Mononucleosis
Psychiatric Treatment
Tuberculosis
Other
None
In the event that this student becomes ill, are there any other medical conditions of which we should be concerned?
(Required)
Choose a response.
Yes
No
Please describe those conditions:
You may choose to call your Pastor or Student Director and discuss the conditions personally rather than give this information on this form. Your privacy will be respected
Does this student have any allergies?
(Required)
Choose a response.
Yes
No
Please describe those allergies:
(Required)
Does this student have any physical disabilities?
(Required)
Choose a response.
Yes
No
Please describe those disabilities:
(Required)
Does this student take any medication?
(Required)
Choose a response.
Yes
No
Please list those medications and their dosages:
(Required)
Is this student under a physician's care at this time?
(Required)
Choose a response.
Yes
No
Please upload a statement from your physician telling of the medications, special diet, restrictions as to recreation activites, etc.
(Required)
Max. file size: 25 MB.
In case of emergency:
(Required)
Choose a response.
Call the emergency contact before any treatment.
Give first aid, then call the emergency contact.
Are this student's immunizations up to date?
(Required)
Choose a response.
Yes
No
Please list missing immunizations and reason:
(Required)
When was this student's last tetanus shot?
(Required)
Insurance Information
All participants must provide their own health insurance as the primary source of coverage. Missouri Baptist Convention and its partners will provide no medical, health, life or other insurance to participants.
Does this student have medical insurance?
(Required)
Choose a response.
Yes
No
Insurance Company
(Required)
Policy Number
(Required)
Group Number
(Required)
Student's Doctor
First
Last
Doctor's Phone
Releases
Promotional/Photography Release
(Required)
I give permission for my child’s image through print and video to be used in promotion for future Missouri Baptist Convention events.
Legal and Medical Release
(Required)
I, as parent/guardian of the student listed on this form, release the host church, its agents, and employees, and Missouri Baptist Convention from any claims illness or causes of action arising from or connected with transportation to and from, attendance, and participation in the upcoming Student Evangelism Conference.
I further agree that the host church, its agents or employees, and Missouri Baptist Convention are authorized to provide such medical care treatment as may be necessary, in their judgment, during such transportation and project.
I agree with this statement.
Δ
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About
Information
Who We Are
What We Believe
Vision & Mission
Who We Are
What We Believe
Vision & Mission
People
Executive Board
MBC Directors
Staff Directory
Open Positions
Executive Board
MBC Directors
Staff Directory
Open Positions
Contact
Contact Information
Facebook Page
Dr. Fowler Speaking Request
Contact Information
Facebook Page
Dr. Fowler Speaking Request
Ministries
Making Disciples
Vision for Evangelism & Discipleship
LIFE Outreach
Super Summer
Student Evangelism Conference
Childhood Ministry
VBS
Vision for Evangelism & Discipleship
LIFE Outreach
Super Summer
Student Evangelism Conference
Childhood Ministry
VBS
Multiplying Churches
Cross-Cultural Engagement
Demographics
Multiply Vision
Partnership Missions
Pastoral Mentorship Initiative
Cross-Cultural Engagement
Demographics
Multiply Vision
Partnership Missions
Pastoral Mentorship Initiative
Developing Leaders
Church Revitalization & Replanting
Hunger Relief Network
Leader Care Network
Ministry Wives Network
Pastoral Ministry
Church Revitalization & Replanting
Hunger Relief Network
Leader Care Network
Ministry Wives Network
Pastoral Ministry
Other Ministries
Affiliated Ministries
Apologetics
Collegiate Ministry
High Street Press
The Pathway
WMU
Affiliated Ministries
Apologetics
Collegiate Ministry
High Street Press
The Pathway
WMU
Administration
Executive Office
Executive Board
Governing Documents
Annual Reports and Statistics
Book of Reports
Affiliation, Incorporation, and Church Bylaws
Historical Commission
Nominating Committee
Sexual Abuse Response
Executive Board
Governing Documents
Annual Reports and Statistics
Book of Reports
Affiliation, Incorporation, and Church Bylaws
Historical Commission
Nominating Committee
Sexual Abuse Response
Ministry Support
Annual Church Profile (ACP)
Cooperative Program
Missouri Missions Offering
Workspace Database
Online Giving & Church Remittance
Annual Church Profile (ACP)
Cooperative Program
Missouri Missions Offering
Workspace Database
Online Giving & Church Remittance
Entities
Missouri Baptist Children’s Home
Missouri Baptist Foundation
Hannibal-LaGrange University
Baptist Homes & Healthcare Ministries
Southwest Baptist University
Missouri Baptist University
Missouri Baptist Children’s Home
Missouri Baptist Foundation
Hannibal-LaGrange University
Baptist Homes & Healthcare Ministries
Southwest Baptist University
Missouri Baptist University
Church Benefits
Background Checks
Sexual Abuse Prevention
Compensation Planning
Insurance/Retirement
Background Checks
Sexual Abuse Prevention
Compensation Planning
Insurance/Retirement
None
Annual Meeting
Important Documents
Future Meetings
Videos
Mobile App
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Rules for Messengers
Important Documents
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