Student's Name
*
First Name
Last Name
Student's Birthday
*
MM
DD
YYYY
Does the participant have any physical conditions that could limit his/her ability to participate in any event? If yes, please specify.
List any medications or substances to which the participant is allergic:
Date of last tetanus shot:
MM
DD
YYYY
Does he/she suffer from nosebleeds?
Does participant wear contact lenses or glasses?
Contact Lenses
Glasses
Both
Is the participant currently taking any medication? If yes, list all:
Accident/Health Insurance Carrier:
*
Policy Number:
*
Subscriber:
*
Name 1
*
First Name
Last Name
Relationship to Student
*
Phone
*
(###)
###
####
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name 2
*
First Name
Last Name
Relationship to Student
*
Phone
*
(###)
###
####
I, the undersigned, certify that I am the parent or legal guardian of the above named minor child. I hereby give my consent to have my minor child participate in increased risk and off-site events of Brushy Creek Baptist Church. (A separate form will be filled out for each specific event) I recognize that there are risks involved in participating in these activities and hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in these activities. To the fullest extent permitted by law, I release Brushy Creek Baptist Church, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activities and agree to save and hold harmless Brushy Creek Baptist Church, its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activities. Further, being the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. Any insurance policy of the church or organization sponsoring this event will be used as the secondary coverage.
*
You acknowledge that by Typing in your name below and clicking on the "Submit" button on this website, you are indicating your intent to sign this document and that this will constitute your signature. Custodial Parent Signature
*
Today's Date
*
MM
DD
YYYY
