The FBC Gainesville Student Ministry Medical Release and Permission Form 2019-2020
Youth Name (First, Middle, Last) *
Your answer
Youth Birthday (Month, Date, Year) *
Your answer
T - Shirt Size *
Youth Cell Number
Your answer
Youth Email Address
Your answer
School Name *
Your answer
Year of Graduation *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
ZIP *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Cell Phone *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Name
Your answer
Parent/Guardian Cell Phone
Your answer
Parent/Guardian Email
Your answer
Medical Information
If, necessary describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the church's activity leaders or emergency medical professionals should be aware, and what if any action of protection is required. Submit this notification in writing and attach it to this form. Include names of any necessary medications, dosages and timing that must be taken. Please note that the church cannot accept responsibility for administering prescribed medication.
Medications (currently using)
Your answer
Please list any allergies, what happens (gastro-intestinal problems, breathing, shock):
Your answer
Physician *
Your answer
Office Phone *
Your answer
Insurance Carrier
Your answer
Insurance Policy #
Your answer
Insurance Group #
Your answer
Date of Last Tetanus Shot *
Your answer
Please list and explain any major physical illness or emotional health concerns:
Your answer
Medical, Photo, and Activities Release and Student Covenant
______________________________________________ has my permission to attend all youth activities sponsored by First Baptist Gainesville from Aug 2019-Aug 2020. Any activities that you do not wish your youth to participate in should be submitted in writing to the Youth Minister.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses related to named child.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of the doctor, I/we state that we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by my healthcare provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at our own expense should they become ill or if deemed necessary by the student ministries staff.

Photo Release: I give permission for the church to use photos of my child for information or promotional materials.

Student Covenant: I promise to show respect and create a safe environment (No Drugs, alcohol, or tobacco products on Youth events, no bullying, no cliques) on all youth events.*

*Students who fail to comply with these expectations on any given event could be sent home at their parent’s expense.

Youth's Name *
Your answer
Parent/Guardian Signature *
Your answer
Date of Signature *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service