First Baptist Church Webster

Youth's Full Name (Required)

Nickname

Birthday (Required)

Age (Required)

Gender (Required)

Male

Female

Address (Street, City, State, Zip Code) (Required)

1st Emergency Contact Name (Parent) (Required)

1st Emergency Contact Phone Number (Required)

2nd Emergency Contact Name (Parent or Other) (Required)

2nd Emergency Contact Phone Number (Required)

3rd Emergency Contact Name (Other)

3rd Emergency Contact Phone Number

Primary Physician Name

Primary Physician Phone Number

Please list any known medical conditions (or write "NONE"), includes allergies, asthma.... (Required)

Please list any current medication (or write "NONE") (Required)

Last TETANUS shot

Medical Insurance Provider

Medical Insurance Provider PhoneNumber

Medical Insurance Policy/Group Number

Medical Insurance Subscriber ID

Medical Insurance Policy Holder Name

Relation to this Youth

WAIVER: TO BE FILLED OUT BY PARENTS OR LEGAL GUARDIANS OF PARTICIPANTS WHO ARE UNDER 18 YEARS OF AGE (Required)

I, the parent and/or legal guardian of the youth named above in this form, who is a minor, hereby acknowledge that said minor is presently under my care, custody, and control. I hereby give my child, the said minor, permission to participate in any and all activities at and with First Baptist Church of Webster, Texas, in which he/she, with my approval, registers to participate.

Yes, my youth will be participating

No, my youth will not be attending any youth functions

WAIVER (continued) (Required)

I further expressly grant my permission for my child to participate in all activities while an active participant on trips and church events. In the event that there rises an emergency, necessitating medical and/or surgical attention, I hereby consent and give my permission to the First Baptist staff, its representatives, or the sponsors, or any attending physicians, to make such decisions and to perform such medical treatments and/or surgery upon said minor which may in their sole discretion be necessary and proper under the circumstances.

Yes, my youth will be participating in activities

No, my youth will not be attending any youth functions

WAIVER (conitnued) (Required)

I, the undersigned parent and/or legal guardian of said minor, do release, acquit, discharge, and covenant to indemnify and hold harmless First Baptist Church or its representatives, or the sponsors, or any attending physician, from any and all actions and causes of actions, related risks and dangers, including negligence, damages, liabilities arising out of the treatment of any sickness or accident, and financial responsibility for all medical treatment of any sickness or accident, and financial responsibility for all medical treatment provided during the attendance of any trips. I also assume responsibility for providing transportation home from the event location should it be necessary for disciplinary reasons. My typed name below serves as my electronic signature and acknowledgement of all the above.

My email address is (Required)

Today's Date (Required)