Name *

First Name

Last Name

Date of Birth *

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Cell Phone *

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Home Phone

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Emergency Contact *

First Name

Last Name

Cell Phone *

(###)

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Last Tentanus Shot *

MM

DD

YYYY

Do you have medical Insurance? *

Yes

No

If you have any medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is involved in any activity with FBC, Mound City, in the course of one year from day's date: *

MM

DD

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Name on Insurance

First Name

Last Name

I understand in the event medical intervention is needed, every attempt will be made to contact the person listed above. In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my child if deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. I understand reasonable safety precautions will be take by First Baptist Church and its leaders during all events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold First Baptist Church, Mound City, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. *

I agree

Below is acting as your Signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone

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Name *

First Name

Last Name

Phone

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