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Parental Consent/Medical Treatment Form

Name of Church: First Baptist Church, 1111 E. Hwy 50, O’Fallon, IL 62269
Event: DNow Date: Feb 4-6, 2011

I, the undersigned parent or guardian of , a minor, do hereby authorize adult

workers with the youth of the above named church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis
or treatment and hospital care which is rendered under supervision of any physical or surgeon licensed under the provisions of the
Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of
said physician or at said hospital.
Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may
receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying
me, and do further agree to hold harmless the Church, its staff and sponsors from any claim resulting from such medical
It is also my understanding that my child is attending the above event, including traveling to and from the church and
all points in between. Transportation is provided and arranged by FBC O’Fallon and its sponsors. Furthermore my child has
permission to participate fully in all activities and events related to said event, including all recreational activities, unless
specifically restricted in writing below. I hereby assume all mentioned risks including those which are not specifically
foreseeable, and will hold FBC O’Fallon, including its staff and sponsors, harmless from any and all liability, claims and
demands of every kind whatsoever, whether for bodily injury, property damage or otherwise.
While participating in the above event, I hereby grant permission to the Church to use my child’s photograph on its
website or in other official church printed publications without further consideration and acknowledge the Church’s right to crop
or treat the photograph at its discretion. I also acknowledge that the Church may choose not to use my photo at this time, but
may do so at a later date. I also understand that once my image is posted on the church website, the image can be downloaded by
any computer user, on or off site. Therefore, I agree to hold harmless the Church, its staff, sponsors, employees and agents from
any claims resulting from the use of the photographs or images.
(Please print the following information)
Insurance Co./Group: Policy #:
Hospital Preference: Physician:
Student/Participant Info:
Name: Cell Number:
Address: City: State: Zip:
Gender: M F Birthdate: / / Grade: School:
I am a: Member of FBCO Regular Attender  Guest of (Name/Grade)
Parent/Guardian Contact Info:
Parent(s) or Guardian(s):
Phone Number(s): (Home) (Cell) (Work)

I give consent to adult youth workers of the Church to dispense the following over-the-counter medications to my child
according to the instructions found on the medication should the need arise. (STRIKE THROUGH ANY MEDICATION THAT
Tylenol (Children’s) Cough syrup Benadryl Cream Pepto Bismo/Mylanta
Tylenol (Adult) Cough drops Benadryl capsules/tablets Imodium AD
Ibuprofen (Adult) Throat spray Neosporin Eye drops (Visine)
Naproxen (Aleve)

Special Instructions and/or restrictions (please include any allergies or dietary restrictions) – Attach a sheet if necessary.

Signature of Parent or Guardian: Date:

1. Maintain Christian Conduct at all times.
2. The adult sponsors are in charge.
3. All Rules are to be followed! (FBCO’s & Location’s)
4. Be where you’re supposed to be when you’re supposed to be there!
(Make sure no one has to go around looking for you!)
5. Have fun but be respectful when it’s time to worship or listen to teachings.
6. Treat the property of others with great respect.

Students must dress appropriately for the activity or event and in keeping with HIGH Christian ideals. (For example,
NO sleeveless shirts and at minimum finger-tip lengths shorts). It will be up to the discretion of the leaders and/or
Youth Minister to enforce these guidelines.

Cell Phones
MUST REMAIN OFF and used only with permission of Adult/Leader. Cell phones will be held at night and returned
each morning or confiscated if abused.

Christian Music only. (sponsors have the right to make the final decision)
No personal electronics (video games, etc.), unless permission given in advance and only with sponsor’s
approval (i.e. on the bus).
No Television! Don’t even ask!

General Information
Problems following these Guidelines result in one or more of the following:
Loss of privileges for the event
Special duties appropriate for the violation
Next trip spent in leader’s “hip pocket”
Missing the next special event
Parents called & youth sent home
Any damages or restitution will be paid by parents
Further follow up will be made after conferences with all parties (parents included).


Student: Parent/Guardian:

Rooming Request: (Name & Grade) NO GUARANTEES!!