2024 BOHBC Consent Form

If the Parent/Guardian wishes to rescind any portion of this agreement they may do so at any time with written notice to Black Oak Heights Baptist Church. 405 Black Oak Drive. Knoxville, TN 37912.

Child's Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Current Grade*

School Attending*

Child’s cell phone (if applicable)

Please enter a valid phone number.

Mother's Name*

Cell Phone*

Mother's Email*

example@example.com

Father's Name*

Cell Phone*

Father's Email*

example@example.com

I give permission for my child(ren) to take part in all Black Oak Heights Baptist Church Ministry events and activities for the year 2024. I hereby release Black Oak Heights Baptist Church, and its staff or Adult Chaperones from responsibility and liability for any injury or illness that my child may sustain during these activities. In an event of an emergency, I hereby authorize the adult supervisor of these activities as agent for me to consent to any medical, dental, surgical, treatment and care deemed necessary for my child by a licensed medical or dental professional. Every attempt will be made to contact the parent/guardian with information provided prior to emergency care but if such a situation arises and I am not available it is my desire that my child(ren) be taken care of immediately. I agree to keep current contact information on file with BOHBC. I further agree to pay all charges for the medical, dental or hospital care or treatment. *Copy of Insurance card is required for Medical I give permissionI do not give permission

I give permissionI DO NOT give permission

I give permission for my child(ren) to be photographed/recorded while taking part in all Black Oak Heights Baptist Church Ministry events and activities for the year 2024. I, on behalf of all participants, hereby release and discharge and agree to hold harmless BLACK OAK HEIGHTS BAPTIST CHURCH, its directors, officers, employees, volunteers, and independent contractors, from any and all claims or damages, including but not limited to defamation or violation of rights of privacy or publicity, arising from or associated with the recording or use of the recordings. This release shall be construed, interpreted, and governed in accordance with the laws of the State of Tennessee, and should any provision of this release be determined invalid, such invalidity does not affect any of the remaining provisions. I give permission I do not give permission

Please add contact information other than parent information:

I give permissionI DO NOT give permission

Emergency Contact #1*

Phone*

Emergency Contact #2

Phone

Family Physician*

Phone

(Please send a picture of your insurance card to our office at 865-919-2554)

Medications the individual is currently taking:None

Medications the individual is allergic to:

Do we have permission to administer over the counter medications: Please specify (Tylenol, Bendadryl, Aspirin, Advil, etc

Insurance Carrier*

Insurance ID #

Medication the individual is currently taking: List below or answer “none”*

Medication the individual is allergic to: List below or answer “none”*

Do we have permission to administer over the counter medication:

No - Please enter NONE to answer the next questionYes.- Please Specify in the next questions

Please specify (Tylenol, Bendadryl, Aspirin, Advil, etc.)*

Today's Date*

Date

Parent/Guardian Signature*

Parent/Guardian Name (print)*

Child Cell Phone (if applicable)

Please enter a valid phone number.

EVENTS PERMISSION AND MEDICAL RELEASE

MEDIA RELEASE