First Hot Springs - FBC Waiver

Participant Information

First & Last Name

Address

Phone Number

Date of Birth

Gender
Male
Female

Parent/Guardian #1

Parent First & Last Name

Parent phone and email

Parent or Guardian #2

Parent First & Last Name

Parent Phone & Email

Family Physician

Name

Phone Number

Preferred Care Facility

Insurance

Company Name

Policy Number

In the event of an emergency, give the name and phone number of friends or relatives we can contact who will know how to reach parents or guardians. You MUST complete this information.

Emergency Contact #1 - Name and Relationship to registrant

Phone Number

Emergency Contact #2 - Name and relationship to registrant

Phone Number

Allergies
Food
Drugs
Insect Stings/Bites
Other

Specific allergies

Previous operations or serious illnesses

Current Medications

Any other specific instructions

Permission and Release

Medical Treatment Permission

My permission is granted for the staff members or the designated/approved church representatives of FBC Hot Springs (FBCHS) to obtain necessary medical attention in case of sickness or injury to my child. I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge all sponsors and First Baptist Church Hot Springs, and its staff/representatives, from any and all claims, demands, actions, or cause of action, past, present or future arising out of any damage of injury while employed by or participating in FBCHS events. The rights, powers, and authority of said representatives to exercise any and all of the rights and powers herein granted shall commence and be in full force and effect on the date listed below, and such rights, powers and authority shall remain in full force and effect thereafter until revoked by me in writing.

Child's Name

Photos and Social Media: At all children’s ministry events, digital pictures are taken for the sole purpose of promotion. I understand that my son/daughter’s picture may be used on our website or publications to promote FBCHS events.

Media Release
YES, I understand and agree
NO, For legal reasons, images of this child may not be posted online

Transportation Permission: The undersigned does also hereby give permission for my child to ride in any vehicle driven by a licensed ADULT chaperone while attending and participating in children & youth’s activities sponsored by First Baptist Church Hot Springs. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

I understand that my child’s FBC Medical Treatment Permission, Photograph/Video/Social Media Permission & Release of Liability Form will remain on file in the church office until my child graduates from high school or is revoked by me in writing. It is my sole responsibility to notify the church office if any information changes
I understand

Please type your name below. This will serve as your signature.

FBC Waiver

Participant Information

Parent/Guardian #1

Parent or Guardian #2

Family Physician

Insurance

In the event of an emergency, give the name and phone number of friends or relatives we can contact who will know how to reach parents or guardians. You MUST complete this information.

Permission and Release

Medical Treatment Permission

Contact Info

Service Times

About First Hot Springs

Service Times

Contact Info