High School Serve 2019
Please fill out this form to sign up for High School Serve
July 21st- 28th
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Birthday *
MM
/
DD
/
YYYY
Grade *
Your answer
Gender *
T-shirt Size *
Insurance Carrier & ID Number *
Your answer
Name of Primary Insurance Holder *
Your answer
Date of Birth of Primary Insurance Holder *
MM
/
DD
/
YYYY
List any allergies, special food needs or restrictions, and any other important medical information
Your answer
I have medical concerns about my child’s involvement in strenuous physical activity (please describe):
Your answer
List any medications your student will need to take during the trip (times and amounts)
Your answer
Date of last tetanus shot
MM
/
DD
/
YYYY
Permission to give common medicines (Overnight trips only)
Permission to give common medicines (Overnight trips only)
I give the trip leaders permission to administer the following medications if my child is seen to be in need of them:
OTC Medications
Parent Name *
Your answer
If you and your family attend a church, what is the name of the church?
Your answer
Home Address *
Your answer
Primary Phone Number *
Your answer
Work Phone Number
Your answer
Parent's Email Address *
Your answer
Emergency Contact Name (1) *
Your answer
Emergency Contact Phone Number (1) *
Your answer
Emergency Contact Name (2) *
Your answer
Emergency Contact Phone Number (2) *
Your answer
Do we have permission photograph your child? *
Do we have permission to use your child’s photograph in church publications? *
Permission
I understand that there are inherent risks involved in any event, and hereby release First Baptist Church, its staff and volunteer workers from any and all liability due to an injury, loss or damage to person or property that may occur during the course of this trip.

I understand that First Baptist Church and its staff and volunteers are committed to providing safe, fun and educational activities, and that all youth activities are conducted in a smoke-, alcohol- and drug-free environment. In light of this, and to help ensure the safety of all concerned, I understand that if my child is in possession of drugs, alcohol or tobacco products, engages in any illegal conduct, or refuses to follow the directions of trip leaders or volunteers while participating in this activity, I will be telephoned to immediately pick up my child.

In the event of a medical emergency, I wish to be contacted as soon as possible. I declare that I am the child’s parent or legal guardian and hereby authorize the First Baptist Church staff and volunteers, as agents for me, to consent to X- ray exams, and other medical, dental, or surgical diagnosis and treatment, advise and supervised by a physician, surgeon or dentist. This authorization extends to any emergency room treatment, and admission and treatment as an inpatient, considered necessary by the attending physician.

I understand that my student will be transported by First Baptist Church staff and/or volunteers.

I give consent for my child to participate in water sports or other outdoor adventure activities if they are offered and if he/she chooses to participate.

By clicking "I agree" below, you are agreeing the statements above.

Permission Agreement *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service