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HEALTH RECORD, CONSENT FOR TREATMENT, AND RELEASE 

Note: Parent/Guardian - It is important that you complete the following Health Record. Copies of this paperwork will be maintained in the Church office and taken on in-town, overnight and out of town trips.

EXPECTING THAT THE LEADERS FOR ANY EVENT/TRIP WILL EXERCISE REASONABLE CARE IN OVERSEEING THE ACTIVITIES OF THE STUDENTS, I REQUEST AND AUTHORIZE THE LEADERS TO SEEK WHATEVER MEDICAL CARE IS NECESSARY AND ADVISABLE SHOULD AN EMERGENCY ARISE WHICH WOULD REQUIRE TREATMENT FOR MY SON/DAUGHTER.

In order that my son/daughter may receive the proper medical treatment in the event that he/she may sustain injury or illness during a church activity, I hereby authorize the leaders to obtain or provide medical treatment for my son/daughter for such injury or illness during the activity, and I hereby hold harmless First Baptist Church of Fairhope, Alabama Inc. and the leaders, in the exercise of this authority.

I further understand that there is always a possibility that my son/daughter may sustain physical illness or injury while participating in an event. If this occurs, I hereby authorize First Baptist Church of Fairhhope, Alabama Inc. and the leaders to refer my son/daughter for medical treatment, including a medical treatment center (hospital, etc.). I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my son/daughter for physical illness or injury that he/she may sustain during the event/trip.

Understanding that there is always a possibility that my son /daughter may sustain physical illness or injury, I acknowledge and understand that my son/daughter is assuming the risk of such physical illness or injury by his/her participation, and I further release and hold harmless First Baptist Church of Fairhope, Alabama Inc. and the leaders from liability for any and all claims for personal illness or injury that my son/daughter may sustain during the event/trip named above.

I understand that, in the event my child requires medical or dental treatment while engaged in the activity, reasonable efforts will be made to contact me; however, if I cannot be reached, I hereby consent and give permission to the ministry’s sponsor or any adult counselor acting on behalf of the ministry with respect to the Activity, as agent for me to consent to any X-ray examination; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child’s medical allergies, medications being taken, medical problems and other pertinent information.

Annual Liability Release Form
Release of All Claims - Minor Participants

In consideration of being accepted by First Baptist Church of Fairhope, Alabama Inc. for participation in all church activities, events or trips to be held during the next year, we (I), being 19 years of age or older and parent or legal guardian of minor listed below for ourselves and on (Student/Child’s name) behalf of the child-participant do hereby release, forever discharge and agree to hold harmless First Baptist Church of Fairhope, Alabama Inc., its staff, employees, leaders, directors, volunteers and any other agents (hereinafter called “agents”) from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and/or the child-participant that occur while said child is participating in any church activity, event or trip, irregardless of the location(s) of such activity, event or trip.

Assumption of Risk

Furthermore, we (I) assume all risk of personal injury, sickness, death, damage and expense as a result of participation in all aspects of the above referenced activity/event for ourselves and on behalf of the child participant. Such risks may include exposure to other participants who are ill or have special medical conditions.

Indemnification

The undersigned agrees to hold harmless and indemnify First Baptist Church of Fairhope, Alabama Inc. and its agents for any liability and related expenses sustained by said Church as the result of the negligent, willful or intentional acts of said participant.

Medical Treatment Authorization

Permission is granted to take said participant to a doctor of hospital if needed. We (I) authorize medical treatment, including but not limited to emergency surgery, and assume the responsibility of all medical bills, if any.

Unplanned Transportation Costs

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) assume all transportation costs and as appropriate, to fully indemnify and / or reimburse First Baptist Church of Fairhope, Alabama Inc. or its agents.

Photo/Audio/Web Release

Further, we (I) consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the child-participant during their participation in any activity, event or trip to be used, distributed, or shown as said Church sees fi t including but not exclusive to: slide shows, church website, print media and local newspapers.

Parental Permission Release Form

I (we), the parent(s) of (student/child’s name), hereby give permission for my student to attend and/or participate in events and trips with First Baptist Church of Fairhope during the year of TBD. I understand that travel will be provided by Church bus/van unless otherwise notified.

We understand that First Baptist Church of Fairhope, Alabama Inc.does not represent that swimming will be supervised by professional or certified lifeguards. In consideration of (Student/child’s name) being allowed to go on any said (Student/child’s name) trip during the year of TBD, we release First Baptist Church of Fairhope, Alabama Inc., it’s staff, chaperones, and members from any claim or cause of action for injury, sickness, damage or loss of whatsoever nature sustained on said trip, and we agree to protect, indemnify, and hold harmless First Baptist Church of Fairhope, Alabama Inc. its staff, chaperones, and members and to pay them all sums which they may be subject to pay in consequence of any claim by, or injury, sickness or death to (Student/Child’s name).

We also give permission for any hospital, physician or medical personnel to administer treatment as needed to (Student/Child’s name) in case of illness or injury.

Today's date: February 29, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Third Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Fourth Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Fifth Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Sixth Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Seventh Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Eighth Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Ninth Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Tenth Participant's Name

First Name*

Middle Name

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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:*
If Parent/Guardian not available in an emergency, notify:

Name

Relationship

Phone Number

Address

Name

Relationship

Phone Number

Address
Insurance Information

Is there medical or hospitalization insurance which provides benefits for this child? If so, please indicate:


Name of Insurance Co.

Address

Policy No. of Insurance Policy

Name of Policy Holder

Phone No. of Insurance Co.
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*

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

AGE:

Past Medical History

Does this child have any of the following allergies?


Pencillin

Other Drugs

Insect Stings

Poison Ivy, etc.

Hay Fever

Other:

Is the student presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details (name of drugs, dosage, etc.)

Indicate the date of last TTB (Tetanus, Dip Tox, Booster shot)
Is your son/daughter living with:
Both parents
One parent
Guardian

If living with one parent, please indicate any non-custodial issues we should be aware of:

Previous Operations or serious illness:
Has your child had any of the following childhood diseases?
Chicken Pox
Measles
Mumps
Whooping Cough
Does this child have any medical or health problems, and has this child had any chronic or recurring illness or illnesses, which would have an effect on the child’s participation in this Activity?*
No
Yes

If yes, describe the problems or illnesses:

State the name, address, medical specialty and phone number of this child’s family physician and of any other physician who should be consulted in the event of emergency or medical problems involving this child:

State the name , address, and phone number of this child’s dentist (and orthodontist if applicable):

IF SWIMMING IS INVOLVED.......

We understand that swimming can be a dangerous activity and also understand that it is important for First Baptist Church of Fairhope, Alabama Inc. to be fully informed as to the swimming ability of my (our) child.

As such, I (we) are familiar with the ability of my (our) child to swim and rate his/her ability as follows:
My (Our) child does not have my (our) permission to go swimming during any activity.
My (Our) child has little knowledge of swimming and does not have confidence going under water.
My (Our) child has some knowledge of swimming and is able to swim in water over his/her head.
My (Our) child is a good swimmer and has confidence swimming underwater and in water over his/her head.
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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