Child's Name

Parent(s)/Guardian(s) Name

Your Email

Address

City

State - Zip Code

Home Phone

Cell Phone

Child's Age

Date of Birth

Child's Grade In School

IN CASE OF EMERGENCY

Primary Contact

Phone Number

Secondary Contact

Phone Number

Allergies or Medical Conditions (if any)

Dietary Restrictions (no milk, peanuts, etc.)

Any additional information you would like to provide

Medical Insurance Company

Phone Number

Name of Policy Holder

Relationship

Medical Insurance Group and Policy Numbers

Physician

Phone Number

Dentist

Phone Number

My child has my/our permission to ride to and from church and church activities in the van or bus operated by First Free Will Baptist Church, 1461 Timbers Drive, Dothan, AL (hereinafter called the "Church"). This consent form gives permission to seek whatever medical attention is deemed necessary and releases the Church, its staff and volunteers of any liability against personal losses of child named above.

Parent/Guardian Consent and Release:

I/We, the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/We hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and /or hospital personnel designated by the Church, I/We agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member

consent and release

Type Full Name

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