Student Ministry
FirstBaptistChurch, Copperas Cove, Texas
Registration and Medical Consent Form
Minors Name: ______Phone: ______
Address: ______
Birthdate: ______Sex: ______
SSN#: ______(Please note that without the Social Security Number, we will be unable to provide your student health care in the case of an emergency. The hospital must have that information. It will be used for no other purpose, and will be kept in a secure location.)
EMERGENCY INFORMATION
Insurance Co and policy number: ______
Dr. Name and phone number: ______
Dentist Name and phone number: ______
EMERGENCY CONTACTS
Name: ______Name: ______
Home phone: ______Home phone: ______
Cell phone/pager: ______Cell phone/pager: ______
Work phone: ______Work phone:______
Health History and Allergies (please check all that apply)
Drugs Diabetes Physical Handicap
Asthma Cardiac Emotional Handicap
Hay Fever Chronic Asthma Mental Handicap
Insect Stings Nervous Disorder Seizure Disorder
Other Food Allergies Epilepsy
Date of last Tetanus Shot: ______
Activity Restrictions: ______
If you have checked any of the above, please give details: ______
______
This applies to: ______date: ______
Parent/Guardian signature______
Student Ministry
FirstBaptistChurch, Copperas Cove, Texas
Consent and Release from Liability
I, (parent/guardian)______hereby acknowledge that itis my desire that my child, participate in church-sponsored activities with FBC, Copperas Cove, Texas, including activities on and/or awayfrom the church premises as well as transportation to and from theseactivities. I am voluntarily allowing my child to participate in these activities,including transportation to and from such activities, with knowledge ofthe dangers involved and hereby agree to accept any and all risks ofinjury as a result of such participation and transportation. As lawful consideration for permitting my child to participate in suchactivities, including the transportation to and from such activities, Ihereby release and discharge FBC, Copperas Cove, Texas, itsemployees and chaperones fromall action, claims and demands which I, my child, or guardians of either of us have or mayhereafter have for any injury or damages resulting from negligenceor other acts, however caused, by such church, employees or chaperones, before, during or after my child'sparticipation in such church-sponsored activities on and/or away fromthe church premises, including transportation to and from suchactivities. I have carefully read this agreement and fully understand its contents. I am aware that this is a release of Liability and an assumption of risksand I am signing it of my own free will. This consent and Release from Liability shall remain effective untilrevoked in writing and delivered to any ministerial staff of FBC, Copperas Cove, Texas.
(Parent Signature) ______(Date)______
FOR YOUTH:
I, the undersigned Youth, promise to do my best to cooperate with the leaders of any youth activity in which I participate. I realize that when the group is out of town, if I am uncooperative and it causes me to be a burden on the group or the leaders, I will be subject to being sent home at my expense. I acknowledge that I am an example for Christ and the image of this church, and I will do all I can to reflect that positively.
(Student Signature)______(Date) ______