Child’s Name __________________________________________________________________________

Address ______________________________________________________________________________

____________________________________________________________________________________

School & grade: _____________________________________________ D.O.B. ____________________

Parent(s)/Guardian(s) ____________________________________________________________________

I give permission for my child (above) to attend events sponsored by First Baptist Church, Charlotte, MI. Knowing that the adult chaperones will give utmost care to my child's safety, I understand that accidents do occur and that in such situations immediate steps must be taken to secure my child's health. I hereby authorize the staff and chaperones of Charlotte First Baptist Church to seek immediate medical attention by a local health officer and/or at the nearest emergency facility for my child should an emergency arise. I understand that all efforts will be made to contact me.

I hereby release First Baptist Church, it’s staff and sponsors, from responsibility and liability for any injury or illness that my student may sustain during this activity, as agent for me, to consent to any X-ray, examination, medical, dental or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon or dentist licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital.

Parent/guardian home phone_______________________________________________________________

Parent/guardian work phone_______________________________________________________________

Parent/guardian cell phone (list parent) _______________________________________________________

Emergency Contact Person ________________________________ Phone: __________________________

E-mail________________________________________________________________________________

Insurance Company Name_________________________________________________________________

Policy No and Member’s Name ____________________________________________________________

Allergies _____________________________________________________________________________

Current medications and ailments ___________________________________________________________

____________________________________________________________________________________

Handicaps or Limitations (Physical or otherwise) ________________________________________________

____________________________________________________________________________________

Parent/guardian's signature________________________________________________________________

Date_________________________________________________________________________________

FIRST BAPTIST CHURCH

1110 S COCHRAN AVE ¿ CHARLOTTE, MI 48813 ¿ 517.543.6900

Becky Crouch – Director of Children’s Ministries / Ryan Manning – Director of Youth Ministry