B3Students Medical Release & Liability Waiver
The completion of this form is required for all students who are participating in Arran Lake Baptist Church Student Ministry events.
Student Full Legal Name *
Your answer
Address *
Your answer
Student Phone (if available)
Your answer
Parent/ Guardian Full Name *
Your answer
Parent/ Guardian Cell *
Your answer
Parent/ Guardian Email: *
Your answer
Insurance Company *
Your answer
Insurance Policy Number
Your answer
Student Primary Care Name
Your answer
Student Primary Care Phone Number
Your answer
Please list any current or previous medical problems or allergies we should be aware of. If your student does not have any known medical problems or allergies, please indicate by typing "none". *
Your answer
Please list any medications (prescription & non-prescription) your teenager is currently taking and proper dosage. If your student does not take medication, please indicate by typing "none". *
Your answer
Date of last tetanus shot. If unavailable, indicate that it is up-to-date
Your answer
Describe your students ability with regard to swimming. *
Please list any physical conditions we should know about concerning your student. *
Your answer
I hereby grant permission for my teenager to participate in all B3Student activities, including Sunday morning, Sunday night, Summer, and any other activity approved by B3Students and its leaders. *
Required
I grant permission for any medical assistance deemed necessary by qualified medical personnel to be conducted on my teenager should an emergency arise and I am unable to be contacted. *
Required
I release Arran Lake Baptist Church of Fayetteville, NC, it’s pastor, staff & chaperons from the liability of any accidents which may occur. *
Required
Arran Lake Baptist Church and B3Students want to make sure that we are transporting your student(s) in the safest possible manner. As we travel to different functions, it is not always possible to drive the bus. Sometimes, we have leaders drive and sometimes we have students drive themselves or ride with other students if they are able. Please indicate below your desired option for transporting your student(s). *
Required
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