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 Thank you!

Youth Permission/Medical Form

"*" indicates required fields

Child's Name*
MM slash DD slash YYYY
Physical Address if Different from Mailing Address
Mother's Name*
Father's Name*
Emergency Contact*
My Child Does NOT Have Insurance
Include special medical needs or concerns such as asthma, allergies, conditions, dietary needs, medications, etc.
This field is for validation purposes and should be left unchanged.