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Permission Form For Franklin Heights Baptist Church Student Ministries |
Event name: Event date:
(please print)
Participant Name: Grade: ________
Parent / Guardian:
Telephone (mother): (DAY): (NIGHT):
Telephone (father): (DAY): (NIGHT):
Address: City/State: Zip: _
Church: Participants Email:
In case of emergency and the above persons can not be contacted, please notify:
Name: Relationship:
City of Residence: _
Telephone: (home) (cell) _
Medical Authorization
I understand that the program will be under the supervision and direction of one or more adult leaders, sponsors or chaperons from Franklin Heights Baptist Church and will involve activities either on or away from the Church Campus and Grounds. I understand that any transportation will be provided by insured responsible adult drivers. I WAIVE ANY CLAIM AGAINST FRANKLIN HEIGHTS BAPTIST CHURCH AND/OR ITS APPROVED LEADERS, SPONSORS OR CHAPERONES THAT I OR ANY MEMBER OF MY FAMILY MAY HAVE AS A RESULT OF, OR ARISING OUT OF, THE PARTICIPATION BY THE NAMED PARTICIPANT IN THE ACTIVITY NAMED IN THIS DOCUMENT.
I/we the parents or legal guardian of , a minor, understand that in the case of emergency that the leaders will attempt to contact me prior to medical treatment, but if I can not be reached then I hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed medical personnel on staff of any licensed hospital. This authorization is given in advance of any specific diagnosis, treatment, or hospital care required, but is given to provide authority and power to render care, which is deemed advisable in the best judgment of the physician.
Date: Signature: ___Relationship: _____
Birth date of Minor: ________ Last Tetanus Shot: Social Security Number: _
Allergies:
Medications:
Family Physician: Phone: _________
Insurance Co.: Policy #:
COMMUNITY AGREEMENT for ALL PARTICIPANTS
I agree:
1. NOT to leave the event or grounds without permission of an adult advisor;
2. NOT to bring or use alcohol or any illegal drugs;
3. NOT to participate in any violent behavior, including the possession of weapons of any kind;
4. NOT to smoke or chew tobacco;
5. NOT to participate in any personal displays of affection;
6. TO respect the needs and property of other participants and chaperones;
7. TO participate in community activities, including chores.
8. TO follow the directions of the youth workers and be respectful in doing so.
I understand these agreements are designed to provide a safe and supportive community at all events. I also understand that if I break one of these agreements, I will have broken the trust of the community, and may be asked to leave at the expense of my parent(s)/guardian(s).
Signature of Participant: Date:
Signature of Parent/Guardian: Date: _