Student Name *
Student Name
Date of Birth *
Date of Birth
Student Address *
Student Address
Student Cell Phone
Student Cell Phone
Emergency Contact Name *
Emergency Contact Name
Address (If Different From Student)
Address (If Different From Student)
Emergency Contact Phone
Emergency Contact Phone
Second Emergency Contact Name
Second Emergency Contact Name
Second Emergency Contact Phone
Second Emergency Contact Phone
Do you/your student have health insurance? *
Family Doctor
Family Doctor
Doctor Phone
Doctor Phone
Special Conditions
May we give your student over the counter medication?
Medical/Liability Release *
I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activity sponsored by FBC Albemarle, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. I understand all reasonable safety precautions will be taken at all times by FBC Albemarle and its agents during the course of events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold FBC Albemarle, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. I understand that by checking "Yes," I am agreeing to the above, and that by providing my initials/full name at the bottom of this form, I am agreeing to the above terms.
Photo/Internet Release *
I understand, as a participant of all FBC Albemarle Student Ministry Activities, my student may be photographed during normal activities, and these photos may be posted on the FBC Albemarle website and/or social media platforms. I always reserve the right to pull any picture off the site that I may deem necessary. I understand that by checking "Yes," I am agreeing to the above, and that by providing my initials/full name at the bottom of this form, I am agreeing to the above terms.