Youth travel release 2010

If you have questions, or would like more information, please leave your name and contact information.

First Name:
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Last Name:
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age
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gender

Email Address:
Address:
City:
State:
Zip Code:

Birth Date
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Home Phone
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Emergency contact name
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Emergency Contact Phone
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emergency contact's relationship to student
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Medical Insurance Company
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Medical Ins. comp. Phone
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Medical Ins. Group &/ or Policy #
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Med. Ins. Address City Statezip
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List physical Limitations ( asthma diabetes allergies etc.)
CommentSpecial Medical instructions (medication alergies rare blood type contact lens wearer etc.)
List all medications you take on a regular basis
Parent or legal gaurdian
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As parent or legal guardian of above mentioned minor I hereby acknowledge that said minor is presently under my care custody and control. I hereby give my express permission to travel with the representatives of the student ministry of the First Baptist Church of Crosby Texas. I further give my permission for my child to participate in all activities while on trips. Please initial here
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I have listed above minor's physical conditions or medical problems that may need attention and all medications regularly used by said minor. In the event there arises an emergency necessitating medical or surgical attenetion I hereby consent and give my permission to the first Baptist Church of Crosby or it's representatives or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon said minor which may in their sole discretion be necessary and proper under circumstances. Please initial here.
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I do release aquit discharge and hold harmless the First Baptist Church staff personell or it's representatives from any and all actions damages and liabilities arising out of the treatment of any sickness or accident incurred by my child during the year 2010. Please initial here
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I also give authority and permission to the First Baptist Church of Crosby representatives to inspect my child's room and belongings if applicable while involved in the activities for the safety and protection of all participants if unusual circumstances make any such inspection necessary. Please initial Here
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I understand that my son/daughter will be dismissed from any trip and sent home at my expense if he/she does not adhere to the rules. Please initial here
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Parent or gaurdians full Name
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Parent or Guardian Digital Signature Drivers license
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Security code:
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Do not enter anything in this field:

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