Participant Information
Name *
Birthdate *
Address *
Emergency Contacts
Mother's Name *
Mother's Name
Mother's Phone *
Mother's Phone
Father's Name *
Father's Name
Father's Phone *
Father's Phone
Third Party name
Third Party name
Third Party Phone
Third Party Phone
Health Insurance Information
Phone Number *
Phone Number
Policy Holder *
Policy Holder
Medical Information
Physician *
Physician's Phone *
Physician's Phone
Physician Address *
Physician Address
Medical Illnesses
List details of all significant past medical problems such as:
List all to be taken
Legal Agreement
Medical Attention *
I (we) give my permission for First Baptist Church adult sponsors or other staff person in charge to obtain any needed medical attention in case of illness or injury to my child. I (we) agree to be liable to pay all cost and expenses incurred in connection with such medical treatment pursuant to this authorization.
Liability Release *
I (we) do hereby release, absolve, indemnify, and hold harmless, acquit, and forever discharge all sponsors, organizers, and supervisors of the First Baptist Church, College Station, TX, from any and all claims, damages, liabilities, costs, demands, actions, or cause of action, past, present, or future arising of any damage or injury while participating in any program or activity even if such personal injury or other loss is caused by the ordinary negligence of the church, its employees, staff members or designated sponsors.