BOHBC Consent Form-2025

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.

Childs Name (first and last)

Date of Birth

Date

Childs Address

Current Grade

School Attending

Child's Cell phone - if applicable

Mothers Name (first and last)

Mother's Cell Phone

Mothers Email

example@example.com

Fathers Name (first and last)

Father's Cell Phone

Fathers Email

example@example.com

EVENTS PERMISSION

I give permission for my child(ren) to take part in all Black Oak Heights Baptist Church Ministry events and activities for the year 2025. 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 permission I do not give permission

I give permissionI do not give permission

Media Release

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 2025. 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 permissionI do not give permission

Emergency Contact 1

Phone

Emergency Contact 2

Phone

Family Physician

Phone

Insurance Carrier

Insurance ID

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

Medications the individual is currently taking: If none, please enter none.

Medications the individual is allergic to: If none, please enter none.

Do we have permission to administer over the counter medication?

yesno

Please specify Tylenol Benadryl Aspirin Advil etc.

Todays Date

Date

ParentGuardian Name print

ParentGuardian Signature