YOU MUST FILL THIS OUT COMPLETELY-PLEASE PRINT IN INK.

INDICATE "Non-Applicable" WHEN NECESSARY AND SIGN THE THREE PLACES ON BACK!

Legal Guardian: Address: Zip #'s: we cannot reach parent(s my child may be entrusted to the following people. (Please list two: other than person listed above)

--Indicate all of the following illnesses, diseases, or medical conditions the student has or has had:AsthmaBronchitis Heart Condition Chronic upset stomach Seizures DiabetesDizziness Hemophilia HepatitisKidney Conditions ColitisOther Sinusitis DepressionEpilepsy

List any and all medications you are currently taking on a regular basis:

Please understand that "extremely high risk" activities will NEVER be formally approved, scheduled or endorsed by the Student Ministries of Cullendale First Baptist Church. However, ministry events or trips may place a student(s) near some activities that do involve some risk. It is the parent's responsibility to properly instruct their child in what is acceptable as an activity in concurrence with the CFBC Student Ministry program. In the event a student decides to participate in a non- approved, un-scheduled or un-endorsed activity during "free time" on a trip OR any other time, they do so directly AGAINST the leadership of this program. This form also allows your student to be transported by CFBC vehicles (vans/busses) to youth/church events.

Trip activities, among others, will potentially be endorsed and scheduled by the Student Ministries of CFBC. List any other activities that you forbid your child to participate in: (bungee jumping for example!) Please Ask Questions!

acknowledge that I have read the above high/low risk information and affirm that my child cannot participate in the indicated or checked activities. Other than the indicated or checked activities, I know of no reason why my child should not participate in the activities of the Student Ministries of Cullendale First Baptist Church. Date Parent or Legal Guardian's Signature

Iunderstand that as a participant, my child may be photographed and/or videotaped during Student Ministry activities. These photos/videos may be used in presentations and/or promotional materials. By signing, I release Cullendale First Baptist Church to use these photos and/or videos for Student Ministry activities. Date Parent or Legal Guardian's Signature

FULL PERMISSION AND CONSENT is hereby granted for the Youth Pastor(s), bus/van drivers, Interns/workers, and/or other duly appointed Chaperones of Cullendale First Baptist, to obtain necessary medical and/or dental attention for my child/dependent in case of an emergency through the care of a consulting physician and/or dentist, if the parents or legal guardian cannot be reached. This treatment may include examinations, x-rays, anesthetic, medical diagnosis, anesthesia, surgical procedures or treatment through prescribed medicines. In the event of a major illness or need for surgery, parent's special permission will be sought by the hospital and attending physician prior to treatment. We grant any CFBC staff or representative permission to have knowledge of any diagnosis or treatment needed for my child/dependent.

SPECIAL NOTE TO PARENTS OR GUARDIANS: As the parent or guardian of the above minor, you are responsible to provide any new and important medical information to the Student Ministry office to update this form. The original will be kept on file at Cullendale First Baptist Church. At your request, a copy of this form will be returned to you for your records. This is a very in-depth release form. We want to make sure that we are prepared the best that we can be for any type of situation. However, there are risks involved with virtually every situation and you need to be aware of that. If you have any questions about any of this release form, please contact the Student Ministry office of Cullendale First Baptist, 870-231-5441. Thank you for your help and understanding.