South Texas Release Form

Enter name exactly as it is on participant’s government issued ID (driver’s license, passport, etc.)

BIRTHDAY *
BIRTHDAY
CELL PHONE OF PARTICIPANT
CELL PHONE OF PARTICIPANT
HOME PHONE
HOME PHONE
Allergies / Restrictions
Is the above named allergic to any medications, foods, environmental, or other substances? *
Is the above named restricted from eating certain foods or participating in any activities? *
BEHAVIORAL
Are there any sensory, physical and/or behavioral difficulties that would be helpful for the supervising staff and adult volunteers to know about? *
Medications
Is the above named currently on any medications? *
I authorize First Baptist Church and its volunteers, staff and agents to provide first aid to the above named in accord with their judgment, and this treatment may include the administration of over-the-counter (non-prescription) medications and other medications which the above named 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 and further give consent to any treatment recommended by the medical personnel consulted. I further understand that photos and videos of South Texas Mission Trip 2019 will be taken and authorize the taking and publication of photographs and videos of the above named via the internet or other medium.
I understand that South Texas Mission Trip 2019 may include travel by church vehicles and private vehicles, and such vehicles will be driven by church staff, adult volunteers and/or paid staff. I further understand that South Texas Mission Trip 2019 will include active indoor elements and outdoor activities. I freely and voluntarily assume the risk of personal injury to the above named, even if the result of the negligence is 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 the above named 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.