Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Student Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Cell Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Address (If Different From Student)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone

(###)

###

####

Second Emergency Contact Name

First Name

Last Name

Second Emergency Contact Phone

(###)

###

####

Do you/your student have health insurance? *

Yes

No

Family Doctor

First Name

Last Name

Doctor Phone

(###)

###

####

Special Conditions

Heart Condition

Diabetes

Asthma

Epilepsy/Nervous Disorders

Frequent Upset Stomach

Physical Handicap

Major Illness in the past year?

May we give your student over the counter medication?

Yes

No

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.

Yes

No

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.

Yes

No