Student Medical and Liability Release Form

Student Info

Parent Info

Emergency Info

Medical Info

Medical and Liability Release Form

First Baptist Church of Enterprise designates the Youth Ministry of First Baptist Church of Enterprise by the abbreviation "FBC" throughout this entire form.I (we) herby authorize F BC to take my (our) student to the before named physician or faculty for medical treatment in the event of an emergency in which neither parent can be reached.I (we) herby give permission for my (our) student to attend and participate in activities sponsored by FBC.I (we) herby authorize FBC to transport my (our) student to or from church activities.I (we) hereby authorize FBC to include my (our) student in supervised water activities.I (we) authorize FBC and tis' acting leaders to teach and lead my (our) student in religious lessons and services, which may include prayer and Bible teaching.I (we) hereby authorize any adult, in whose care the minor has been entrusted, to consent to any x—ray examinations, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the medical practice act on the medical staff of licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at the said hospital.I (we) hereby authorize any licensed physician or medical treatment center to treat my (our) student in case of emergency in which the before named physician cannot respond.The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered the aforementioned student pursuant to his / her authorizationShould it be necessary for my (our) student to return home due to medical reasons or otherwise, the undersigned shall assure all transportation costs.I (we) herby release, forever discharge and agree to hold harmless FBC and the directors thereof from any and all liability, claims, or damages for personal injury, sickness, or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned and student—participant that occur while said student is participating in any trip or activity with FBC.Furthermore, I (we) [and on behalf of my (our) student—participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage, and expenses as a result of participation in recreation and work activities involved therein.Further authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.The undersigned further herby agrees to hold harmless and indemnify said church, its directors, employees, and agents for any liability sustained by said participant including expenses incurred attendant thereto.The medical consent and liability waiver provisions hereof shall remain in full force through 2017 and until the student is no longer a member of the Student Ministry of FBC. It is the responsibility of the parents/guardian to notify the church of any changes in medical condition, insurance, guardianship, address, or phone changes.
By typing your name above you are agreeing to the above release form and agreeing that all the information contained in this form is correct
By typing your name above you are agreeing to the above release form and agreeing that all the information contained in this form is correct