FBC Columbus Medical Release Form 2026

Participant Name*

Participant Birth Date*

Date

Participant Home Address*

Participant Grade

Grade number only, i.e. 5

Participant Cell Phone

Please enter a valid phone number.

Parent Cell Phone

Please enter a valid phone number.

Email Address for Follow Up*

example@example.com

Participant T-Shirt Size*

Emergency Contact Name*

(If participant is a minor, list contact information for another trusted adult beyond the one completing this form.)

Emergency Contact Phone*

(If participant is a minor, list phone number for another trusted adult beyond the one completing this form.)

Physician's Name*

Physician's Phone*

Known Allergies (medicine, food, etc.)*

If none, type "N/A"

Describe past serious illnesses or hospitalization with dates*

If none, type "N/A"

List Medicines Taken (especially daily medications)*

Please separate each medicine using a comma (,). If none, type "N/A."

Date of Last Tetanus Injection*

Date

Describe all physical conditions or illnesses which could affect participation in the programs or proper medical treatment (diabetes, epilepsy, poor blood clotting, ADD, ADHD, etc.)*

If none, type "N/A"

Does participant have any needs or exceptionalities that require specific accommodations? If yes, please explain.*

If none, type "N/A"

Health Insurance Company*

Policy Number*

Mother's Name

Mother's Phone (W)

Mother's Phone (C)

Please enter a valid phone number.

Father's Name

Father's Phone (W)

Please enter a valid phone number.

Father's Phone (C)

Please enter a valid phone number.

Medical & Photo Authorization and Release and Indemnification Agreement

I hereby give First Baptist Church of Columbus, GA, as well as its agents, employees, officers, and designees, (collectively "RELEASEE/INDEMNITEE") consent to provide for or obtain any medical treatment for the minor named herein or for me that may be required, as determined by a medical professional, during the minor's or my participation in any activity sponsored by RELEASEE/INDEMNITEE with the understanding that the cost of any such treatment will be my responsibility.

I understand RELEASEE/INDEMNITEE cannot be expected to control all of the risks associated with this activity and RELEASEE/INDEMNITEE may need to respond to accidents and potential emergency situations. I agree to indemnify and hold harmless RELEASEE/INDEMNITEE for any costs incurred to provide medical treatment to the minor named herein or me, even if RELEASEE/INDEMNITEE has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation.

I further agree to release, waive, covenant not to sue, and agree to hold harmless for any and all purposes, RELEASEE/INDEMNITEE from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney's fees and expenses, that may be sustained by the minor named herein or me while receiving medical care or in deciding to seek medical care, including while traveling to and from a medical care facility, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEE/INDEMNITEE. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct.

I also hereby give RELEASEE/INDEMNITEE permission to take and use photos and likenesses of the minor named herein or me for historical and/or advertising/public relations for RELEASEE/INDEMNITEE without remuneration for said likenesses.

(Attach copy of Driver's License or official ID of participant or parent/guardian if participant is a minor)

(Attach copy of Passport if traveling outside USA)

Participant Signature (If minor, parent/guardian signature)*

Date*

Date

FIRST BAPTIST CHURCH, COLUMBUS, GA — MEDICAL CARE, EMERGENCY CONTACT INFORMATION & PHOTO RELEASE