2023-2024 Permission Slip and Medical Release Form

Please fill out and submit the Permission Slip and Medical Release for your minor child. If you have multiple children, you will need to complete a separate form for each.
Youth & Children’s Trips/Activities from August 1, 2023-July 31, 2024
First Baptist Church | 101 S. Collier St. | Centralia, MO 65240




*** This form must be completed and submitted prior to participating in any youth or children’s trip/activity. ***

By submitting this form, you hereby give permission for my son/daughter (based on the child information entered below) to participate in any activity with First Baptist Church from August 1, 2023, through July 31, 2024.  I release First Baptist Church, and the sponsors of this event from liability for any accident that may occur during any youth and/or children’s activities or while traveling to and from these activities. It is my understanding that these trips and activities are approved by the church and will be appropriately chaperoned by adult leaders and parents. 

Additionally, in the event that my child becomes ill or sustains an injury during one of these trips/activities, I give my permission to those in charge to take the necessary steps in administering proper medical treatment. In the event that I cannot be reached by phone, I consent to the administration of treatment to be rendered to my child upon the advice of a duly-licensed physician and/or surgeon. I understand that I am giving permission for my child to engage in these trips and all activities, and I will not hold the staff, First Baptist Church, or sponsors responsible for any incident occurring to my child resulting from reasonable activities during these events.  

I further understand that on occasion videos, photographs, and audio clips are taken at conferences/activities to be used for future promotional material. By registering to attend these events, you are giving permission on behalf of each person in the group to First Baptist Church to use your child’s picture in promotional materials.
Child's information

 
 
 
 
 
 
 
 
Please select one option.
Parent/Guardian Contact Information

Parent/Guardian 1  (required)
 
 
 
Parent/Guardian 2 (optional)
 
 
 
Medical Information

 
 
Prescribed Medication(s):
 
 
 
 
 
 
Insurance Information:
 
 
 
Emergency Contacts

Emergency Contact 1
 
 
 
Emergency Contact 2
 
 
 
Insurance Card Copy

Please attach a copy of your current insurance card (pictures are acceptable). If you cannot submit that here, you can also submit a copy to the FBC Centralia Office.
Submission

Please select all that apply.
 
*By entering my name in the box above, I am providing my digital signature on this form.

Description

Please fill out and submit the Permission Slip and Medical Release for your minor child. If you have multiple children, you will need to complete a separate form for each.