Annual Master Medical & Liability Release Form

Annual Master Medical & Liability Release Form
First Students

First Baptist Church

320 Mayfield Rd, Clinton, KY
Student Pastor

Logan Pickett

Phone: (270) 556-2047
******Effective Period: September 1, 2026 - August 31, 2027******

This information will be received and viewed ONLY by the student pastor, and this information will ONLY be stored in the church office. The following information will not be collected or handed out.
1. STUDENT INFORMATION
Full Legal Name of Student

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Grade
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2. PARENT / GUARDIAN & EMERGENCY CONTACTS
PRIMARY PARENT / GUARDIAN CONTACT:
Parent/Guardian's Name

First NameLast Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student
Email
example@example.com
SECONDARY EMERGENCY CONTACT:
Name

First NameLast Name
Relationship to Student
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone
Please enter a valid phone number.Format: (000) 000-0000.

3. MEDICAL & INSURANCE INFORMATION
Primary Health Insurance Carrier
Policy / Group Number
Policyholder Name

First NameLast Name
Primary Care Physician
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Known Allergies (Food, Drug, Environmental)
Type "none" if student doesn't have any allergies
Current Medications / Dosage
Type "none" if student doesn't have any medications he/she is taking
Physcial Restrictions, Chronic Illnesses, or Special Needs
Type "none" if the student doesn't have any of the following.

4. COVERED ACTIVITES & TRANSPORTATION AUTHORIZATION

By signing this document, I grant permission for my teenager named above to participate in all standard student ministry activities sponsored by First Baptist Church of Clinton, KY for the specified effective year, including:
1. Weekly Services & Meetings: Regular weekly youth group services, Sunday school, and on-site fellowship events at First Baptist Church Clinton.
2. Local Group Outings: Local service projects, recreational events, meals, and day outings within the local area. (Events over 10 miles from the church building, Out-of-State, or Multi-day overnight trips, such as camp, youth conferences, will still receive seperate event-specific consent forms).
3. Transportation: Transportation provided by vehicles owned or rented by First Baptist Church Clinton, or private vehicles driven by authorized church staff or designated volunteer leaders.
5. EMERGENCY MEDICAL TREATMENT AUTHORIZATION
In the event of a medical emergency involving my student while attending a First Baptist Church event or activity, I hereby grant permission to church staff, volunteers, or representatives to seek and authorize emergency medical, surgical, or dental care, as well as hospital admission or transportation.

Every reasonable effort will be made to contact the parent/guardian or emergency contact prior to major medical decisions. I accept full financial responsibility for any medical expenses incurred in connection with medical treatment provided.
6. PHOTO & MEDIA RELEASE
I authorize First Baptist Church of Clinton, KY, to photograph or record video of my child during church-sponsored events and use such media for church publications, presentation slides, and official social media accounts. (Check one box below)

7. LIABILITY RELEASE & HOLD HARMLESS AGREEMENT
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor participant.

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend First Baptist Church of Clinton, KY, its staff, leadership, employees, and adult volunteers from any and all claims, demands, damages, actions, costs, or expenses arising out of or in connection with my student attending events, participating in activities, traveling in authorized vehicles, or receiving medical care. I further agree to compensate the church, its staff, or representatives for reasonable attorney fees and costs arising from any such claim.
8. SIGNATURE & ACKNOWLEDGEMENT
I confirm that all information provided above is complete and accurate to the best of my knowledge.
Parent / Guardian Printed Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Signature
Should be Empty:

Annual Master Medical & Liability Release Form

1. STUDENT INFORMATION

2. PARENT / GUARDIAN & EMERGENCY CONTACTS

3. MEDICAL & INSURANCE INFORMATION

4. COVERED ACTIVITES & TRANSPORTATION AUTHORIZATION

5. EMERGENCY MEDICAL TREATMENT AUTHORIZATION

6. PHOTO & MEDIA RELEASE

7. LIABILITY RELEASE & HOLD HARMLESS AGREEMENT

8. SIGNATURE & ACKNOWLEDGEMENT