161 Flat Creek Trail / Fayetteville, Georgia 30214
ACTIVITY/TRAVEL PERMISSION FORM & MEDICAL RELEASE
Flat Creek Baptist Church must have a completed permission and medical release form in order for your child to participate in any activities involving travel away from the church campus. It is the parent's responsibility to update the form if any information changes.
CHILD'S NAME:
*
First Name
Last Name
DATE OF BIRTH:
*
-
Month
-
Day
Year
Date
MINISTRY AREA:
Preschool (Birth - Kindergarten)
School Age (1st Grade - 5th Grade)
Students (Middle - High School)
IN THE EVENT OF SUDDEN ILLNESS OR ACCIDENT REQUIRING IMMEDIATE ATTENTION, FLAT CREEK BAPTIST CHURCH HAS PERMISSION TO OBTAIN EMERGENCY MEDICAL SERVICES FOR MY CHILD. IF THERE IS AN EMERGENCY, I CAN BE REACHED AT THE FOLLOWING NUMBER(S):
MOTHER'S NAME
First Name
Last Name
MOTHER'S CONTACT NUMBER:
Please enter a valid phone number.
FATHER'S NAME:
First Name
Last Name
FATHER'S CONTACT NUMBER:
Please enter a valid phone number.
ALTERNATE CONTACT:
First Name
Last Name
ALTERNATE CONTACT NUMBER:
Please enter a valid phone number.
IS SPONSOR AUTHORIZED TO APPROVE MEDICAL TREATMENT?
*
YES
NO
IS PARTICIPANT COVERED BY PERSONAL/FAMILY MEDICAL INSURANCE?
*
YES
NO
IF YES, NAME OF INSURER:
POLICY OR GROUP NUMBER:
PLEASE CHECK IF ANY OF THE FOLLOWING APPLY:
Examples of Additional Information:
My child is a good/fair/non-swimmer, My child wears glasses/contacts, List any types of medications we can administer to your child if necessary (Tylenol, Benadryl, Topical Creams). List any activities that should be restricted for any reason.
PROVIDE YOUR ADDITIONAL INFORMATION:
I give permission for my child to be photographed.
YES
NO
My child has my permission to to participate in church activities, be transported by a church van or church charter bus, and receive medical attention if needed.
*
Date
*
-
Month
-
Day
Year
Date
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