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FBC Coushatta Children Ministry
Medical & Liability Release Form

I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of First Baptist Church Children’s Ministry, both on and off church grounds, including the necessary transportation to and from these events and activities.

Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-being of the child affected; (3) I cannot be personally contacted. 

I further agree not to hold First Baptist Church or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless FBC for all claims made and liabilities assessed against them as a result of any event or activity. I release FBC and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity.

Furthermore, I understand and assume the expenses of any property damage caused by my child. Should it be necessary that my child be returned home due to disciplinary action (when on trips), I will be contacted by the leaders and will be responsible to pick my child up and assume the cost of transportation.

  

By signing below, I am acknowledging that I have read through and understand the above statements.


Date: August 19, 2022

First Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
First Participant's Signature*
Second Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Third Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Fourth Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Fifth Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Sixth Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Seventh Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Eighth Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Ninth Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
Tenth Participant's Name

First Name*

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

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
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:*
Insurance Information
  
***ATTACH A COPY OF YOUR INSURANCE CARD (FRONT) *
Valid file types: JPG, GIF, PNG, and PDF
  
***ATTACH A COPY OF YOUR INSURANCE CARD (BACK) *
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Email Address

Email*

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

In Case of Emergency, Please Contact:


1. Name *

Phone *

Relationship to Child/Children *

2. Name *

Phone *

Relationship to Child/Children *
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*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Medical Information


Physician

Phone

Medical Insurance Company

Policy #

Member’s Name

Allergies / Meds

Other
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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