BIRTHDAY *
BIRTHDAY
CELL PHONE OF PARTICIPANT
CELL PHONE OF PARTICIPANT
HOME PHONE
HOME PHONE
Allergies / Restrictions
Allergic to any medications, foods, environmental, or other substances? *
Restricted from eating certain foods or participating in any activities? *
BEHAVIORAL
Are there any sensory, physical and/or behavioral difficulties that you believe would be helpful for the supervising staff and adult volunteers to know about? *
Medications
Is your child currently on any medications? *
I desire for my above named son/daughter to participate in Perry County Mission Trip 2017 and give my permission for him/her to do so. I further authorize First Baptist Church and its volunteers, staff and agents to provide first aid to my son/daughter in accord with their judgment, and this treatment may include the administration of over-the-counter (non-prescription) medications to my child and other medications which my child needs medical care beyond first aid and over-the-counter (non-prescription) medications, I give my consent and permission for such medical care to be obtained on behalf of my child and further give consent to any treatment recommended by the medical personnel consulted. I further understand that photos and videos of Perry County Mission Trip 2017 will be taken and authorize the taking and publication of photographs and videos of my child via the internet or other medium.
I understand that Perry County Mission Trip 2017 may include travel by church vehicles and private vehicles, and such vehicles will be driven by church staff and adult volunteers. I further understand that Perry County Mission Trip 2017 may include outdoor activities, construction-related activities and a Back Yard Bible Club. I freely and voluntarily assume the risk of personal injury to my child (or myself if 18), even if the result of the negligence of First Baptist Church or its volunteers, staff, or agents, and further hold harmless First Baptist Church and its volunteers, staff, and agents and release any legal claims of any kind involving any and all injury, disability, death, or loss or damage to person (including myself, and my child) or property, whether caused by the negligence of the releasees or otherwise.
DATE *
DATE
EMERGENCY CONTACTS
Please list phone numbers in the order we should call.