Permission Form

Please fill out the following information for your child(ren) to participate in our event. A new form will need to be filled out for each child separately. Thanks!

Children’s Permission/Medical Form

"*" indicates required fields

Child's Name*

First Last

Age

Current Grade*

Date of Birth*

School Your Child Attends

Address*

Street Address Address Line 2 City State ZIP Code

Physical Address if Different from Mailing Address

Street Address Address Line 2 City State ZIP Code

Mother's Name*

First Last

Mother's Email

Mother's Cell Phone

Mother's Home Phone

Father's Name*

First Last

Father's Email

Father's Cell Phone

Father's Home Phone

Emergency Contact*

First Last

Relationship to Child*

Emergency Contact Cell Phone*

Emergency Contact Home Phone

My Child Does NOT Have Insurance

Medical History*

Include special medical needs or concerns such as asthma, allergies, conditions, dietary needs, medications, etc.

Name

This field is for validation purposes and should be left unchanged.

Children’s Permission/Medical Form

First Baptist Church Moultrie

Sunday Services

Wednesday Services