Permission/Medical

First Baptist Church Youth Permission / Medical Form

All students are required to have the following document on file in the church office to participate in a church function, activity, or trip. Please fill this out completely and attach a copy of the front and back of your insurance card in an email to [email protected]. Thank you!

Youth Permission/Medical Form

"*" indicates required fields

Comments

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

Child's Name*

First Last

Gender*

Age

Current Grade*

Date of Birth*

School Your Child Attends

Shirt Size*

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.

First Baptist Church Youth Permission / Medical Form

Youth Permission/Medical Form

First Baptist Church Moultrie

Sunday Services

Wednesday Services