VBS Registration and Medical Release Form
Parental Authorization for Student Activities
1 January 2018- 31 December 2018
Parent or Legal Guardian First Name *
Your answer
Parent or Legal Guardian Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone Number *
Please use the format (555) 555-5555
Your answer
Work Phone Number
Please use the format (555) 555-5555
Your answer
Cell Phone Number
Please use the format (555) 555-5555
Your answer
Email Address *
Your answer
Alternate Email Address
Your answer
Permission to Participate
The above named parent(s) or legal guardian, either of which shall be referred to herein as "Parent(s)," of the student named above, herein referred to as "the Minor," has entrusted the Minor into the care of First Baptist Church of Carmel, Indiana, Inc. ("FBC") while the Minor participates in programs, activities, events, transportation or services sponsored by FBC (collectively, the "Student Ministries Program"). By signing this form the Parent(s) grant permission for the Minor to participate in the Student Ministries Program.
Medical Treatment of the Minor
The Parent(s) does hereby authorize the agent(s) of FBC, including pastors, deacons, elders, staff and Student Ministry Program volunteers (collectively, the "Agent(s)") to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital admission and care which is deemed advisable for the Minor by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the laws of the state or country in which such health care services are being sought and the medical staff of any hospital; and to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment to be rendered to the Minor by any dentist, oral surgeon or other dental practitioner licensed under the laws of the state or country in which dental care is being sought, all of the foregoing of which shall be referred to herein as "Health Care Services."

It is understood that this authorization is given in advance of any Health Care Services being required and is given to provide authority and power on the part of the Agent(s) to give specific consent to any and all such Health Care Services for the Minor which the aforementioned surgeon, physician and/or dentist, oral surgeon or other dental practitioner, in the exercise of his or her best judgment, may deem advisable.

The Parent(s) hereby authorizes any hospital or other health care facility which has provided treatment to the Minor to surrender custody of the Minor to the Agent(s) upon the completion of treatment. The Parent(s) hereby agrees to fully pay all costs of medical, dental care incurred for the Minor by the Agent(s) under this authorization.

Emergency daytime phone number *
This will be the first number we call in the event of an emergency.
Your answer
Doctor's name *
Your answer
Doctor's phone number *
Your answer
Doctor's address *
Your answer
Insurance carrier *
Your answer
Policy number *
Your answer
Entering student information
On the following pages, you will be able to register individual students. All students you register must have the same medial release information as listed above. To register students with different medical release information, you must fill out a separate registration form. You will have the option to do this when you complete a registration.
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