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Weekly Events:

  • Middle School and High School Connect Groups on Sunday mornings
  • Student Worship on Wednesday evenings

Monthly:

In addition to our weekly events, our student ministry offers various on-campus and off-campus events such as, but not limited to Summer Camps, Fall Retreats, Mission Trips, King’s Island, Hangout nights, and various other local trips (ie. Scavenger hunts, trampoline parks, baseball games, restaurant raids, movie nights, etc.) for the purpose of outreach and fellowship. Many of these events are offered for both Middle and High School, but some may be age/gender specific. To receive up-to-date information, sign up for our LFstudents Remind texting by texting @lfbchsm for high school or @lfbcmsm for middle school to 81010.

Questions:

Josh Fulkerson // joshf@littleflock.com // 502.955.8760 ext. 3315

PERMISSION TO PARTICIPATE / MEDICAL AUTHORIZATION / RELEASE OF LIABILITY

a. Authorization and Waiver: I authorize the student named above in this registration to participate in all of the 2024-2025 (June 1st 2024 to May 31st 2025) activities at Little Flock Baptist Church (5510 N. Preston Hwy, Shepherdsville, KY 40165); including on-site (Church) and off-site activities: home Bible studies, camps/retreats, trampolines, bazooka ball, lazer-tag, inflatable equipment, water-sports (including swimming, boating, etc), snow sports (including tubing, skiing, etc.), playing sports (basketball, tag, soccer, volleyball and other general student ministry games) attending sporting events (baseball, football, etc.) and vehicle transportation to and from activities. I understand that in the event medical treatment is required for the student listed on this form, every effort will be made to contact me. However, if I cannot be reached I give permission to Little Flock Baptist Church or any adult leader to administer medication and authorize medical treatment by a licensed physician reasonably necessary for the student and I also give permission to the attending health care provider to provide necessary treatment and care, including anesthesia, for my child’s well-being, and bill my insurance. I understand that while the church will take reasonable precautions, the activities involve risk and the possibility of unforeseeable risks.

b. I understand that photographs or videos of the student may be taken at the activities and I give the Church full right to use the students name, voice, signature, photograph, or likeness in any manner and for any purpose that may be deemed appropriate by the church. I waive, release and discharge the Church and their related ministries and organizations, and each of their pastors, directors, officers, managers, employees, volunteers, members, and agents from any and all claims, losses, or expenses arising from or related to my child participating in these church activities. I also agree to indemnify, hold harmless, and defend Little Flock Baptist Church and each of the other parties listed above with regard to such claims, losses or expenses, including without limitation any claims made by or on behalf of the student.  

c. Little Flock Baptist Church protects the privacy of Participants and will not release Participant’s personal information other than name for identification.

d. I HAVE READ AND FULLY UNDERSTAND THIS AUTHORIZATION AND WAIVER. I UNDERSTAND THAT I AM WAIVING AND RELEASING ANY CLAIMS. IF THE STUDENT IS UNDER 18 YEARS OLD, THEN AS THE STUDENT’S PARENT OR GUARDIAN I AM AGREEING TO THIS AUTHORIZATION AND WAIVER FORM BOTH IN MY OWN CAPACITY AS PARENT OR GUARDIAN AND IN A REPRESENTATIVE CAPACITY ON BEHALF OF THE STUDENT.

Today's Date: February 22, 2024



First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Photo/Video
I give permission for LF student ministry to take photos and videos of my student.*
Yes
No
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Grade:

Student Cell:

Parent Cell

Additional Contact Numbers:

Personal Primary Physician

Primary Physician Phone Number

Please list any medical allergies or medication allergies :

Please list any medication and doses being taken:

Please list any medical restrictions or other pertinent medical information:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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