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First Baptist Church Greensburg

Youth Ministry Information & Permission/Medical Release Form

Name of Student____________________________________ Date of Birth_________________________


Age______

Sex _______ School Name_______________________________________ Grade_______

Mailing Address: ________________________________________________________________________


Physical Address: ________________________________________________________________________
City____________________ State_____ Zip________ Students Cell Phone: _______________________
Students E-mail:_________________________________________________________________________

Name of Parent/Legal Guardian: ____________________________________________________________


Home Phone__________________ Cell Phone_____________________ Work Phone_________________
E-mail address:__________________________________________________________________________
Name of Parent/Legal Guardian: ____________________________________________________________
Home Phone__________________ Cell Phone_____________________ Work Phone_________________
E-mail address:__________________________________________________________________________
If you cannot be reached in case of an emergency, please provide the name and contact information for
another adult who can be reached:
Contact Name_________________________________________ Relationship to Student______________
Home Phone__________________ Cell Phone_____________________ Work Phone_________________

Please list any special health conditions which FBC Greensburg should be aware of (such as allergies,
medications, medical conditions, etc.)_______________________________________________________
______________________________________________________________________________________
Please list any physical limitations or activities to which your student should not participate____________
______________________________________________________________________________________
Does your child know how to swim?

No

Yes

If yes:

Beginner

Intermediate

Advanced

Any other notes or information you would like FBC Greensburg to be aware of? _____________________
______________________________________________________________________________________
Health Insurance Provider__________________________ Policy#/Group#__________________________
Name of policy holder____________________________________________________________________

Permission and Release


As the parent (or guardian) of _____________________________________
_____________________________________, who was born on
___________, I grant permission for my son or daughter to attend First Baptist Church Greensburgs
activities and events and authorize First Baptist Church Greensburg and its chaperones, to transport and
supervise my child in connection with his or her attendance at the various activities.
I do further hereby give, release, absolve, indemnify, and agree to hold harmless, First Baptist Church
Greensburg, its Board of Deacons,
Deacons, staff, volunteers, and persons transporting my son/daughter to and
from any associated activities from any claim arising out of injury to my son or daughter, except to the
extent such harm is the result of the intentional misconduct of First Baptist Church Greensburg or such
other party seeking to enforce this release.
Medical Authorization
I hereby authorize First Baptist Church Greensburg and its chaperones to seek and have emergency
medical and first aid administered
administered to the above named student wh
while
ile participating in any events or
activities sponsored by First Baptist Church of Greensburg.
Greensburg
I understand and agree that this form will be valid for the duration of my students time in the youth
ministry of First Baptist Church Greensburg.
Signature_____________________________________________________
Signature_____________________________________________________

Date_________________

Printed Name_________________________________________________
Waiver of Publicity Form
I give permission for the use of any photos, movies, and audio or video tapings of my childs act
activities
ivities in
connection with First Baptist Church Greensburgs Youth Ministry, to be used with FBCs approval as they
see fit for promotional, educational, or religious purposes.
Signature_____________________________________________________

Date___________
Date_________________

Printed Name_________________________________________________
FOR NOTARY PURPOSES ONLY BELOW THIS LINE
STATE OF LOUISIANA
PARISH OF ______________
On this _____________ day of _________________________, 20____, before me personally appeared
_______
____________________________________________________,
_____________________________________________, to me known to be the person who executed the
foregoing instrument, and acknowledged that he/she executed the same as his/her free act and deed.
__________________________________
Notary, State of Louisiana
My Commission Expires: ____________________________