First Baptist Cushing Release Form 2020-2021
Please read & fill out each section carefully.
Student's First/Last name: *
Your answer
Student's Birthday (month/day/year): *
Your answer
Student's Phone: *
Your answer
Parent/Guardian First/Last name: *
Your answer
Parent/Guardian Phone: *
Your answer
Emergency Contact Name & Phone: *
Your answer
Insurance Information:
Name of policy holder & insurance company *
Your answer
Insurance Policy # *
Your answer
Insurance contact phone # *
Your answer
Does your student take medications currently? Please list below: *
Your answer
Food or Medication Allergies? *
Your answer
Are there any health concerns we need to know about for your student? *
Your answer
RELEASE INFORMATION
My student may be attending various events with First Baptist Cushing (FBC). I may or may not be attending events with my student. In the event that my student should need emergency medical attention, FBC and/or any one of its agents or employees is hereby authorized to provide such emergency medical care, including without limitation; medical, dental, surgical care or hospitalization, to my student as recommended or suggested by a physician, nurse, surgeon, or other healthcare professional. I understand that in the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment, or order an injection, anesthesia, or surgery for my child as deemed necessary.

If such emergency care is provided, I understand that my student's health insurance and healthcare information will be provided to the healthcare professional and healthcare institution providing care for my student. I further understand that any expense not covered by my student's medical insurance shall be my responsibility. I understand that FBC, will not be obligated to pay either the healthcare professional or me for any medical expenses incurred on behalf of my student.

There are instances when third party contractors may be used to operate and supervise various events and activities. In those instances where third party contractors are used, FBC, is not responsible for the action of these third party contractors. FBC is also not liable for the actions or activities of participants or sponsors participating in events or activities operated by third party contractors.

I understand all reasonable safety precautions will be taken at all times by FBC and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. In consideration of my student being allowed to attend activities with or at FBC, I, on behalf of my student, hereby waive any and all causes of action, rights of claims or suits which I or my child may have against FBC, its agents, contractors or employees as a result of injury to my student or arising from the decision of FBC, or its agents, contractors or employees to consent for provision of emergency medical care to my student.

I understand that my student may be included in video highlights and/or photographs during the course of the year and that said pictures and videos may be used for promotion of FBC events and/or posted on FBC website and/or other social media pages.

I give authority and permission to FBC, staff and its agents to inspect my student's belongings while on activities, retreats or camps for the safety of my student, other students, staff and agents of FBC and all other participants.

Should it be necessary for my student to return home due to medical reasons, disciplinary action, or otherwise, I assume all transportation costs.
Parent/Guardian Signature
By typing your name below, you are acknowledging and agreeing to the above release information
Signature: *
Your answer
Date: *
Your answer
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