Youth Medical

First Baptist Church Youth Permission / Medical Form

All students are required to have one of the following documents on file in the church office to participate in a church function, activity, or trip. Please fill this out completely and the form on the following page and attach a copy of the front and back of your insurance card in an email to rob@firstmoultrie.org. Thank you!

Child's Name *

First

Last

Gender *

Male
Female

Age

Grade (As of August on This Calendar Year) *

Date of Birth *

mm/dd/yyyy

School Your Child Attends

Shirt Size *

Mailing Address *

Physical Address if Different from Mailing Address

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