Medical Liability

Child's Name(Required)

First Last

Age(Required)

Date of Birth(Required)

Parent or Legal Guardian Email Address(Required)

Enter Email Confirm Email

Address(Required)

Street Address City State ZIP / Postal Code

Emergency Contact(Required)

First Last

Emergency Contact Phone(Required)

Family Doctor

Family Doctor's Phone

Health History

Check all that apply.

Allergies

Insect Stings

Drugs

Other

Explain 'Other'

Other Conditions

If you checked any of the above, please give details.

(i.e. include normal treatment of allergic reactions)

Any Swimming Restrictions:

Yes

Any Activity Restrictions:

Yes

Explain restrictions:

Also list the names and dosage of current medications.

Insurance Company Name

Our church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church-related activity.

Your Insurance Company's Name

Policy Number

Group Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Today's Date(Required)

Upload a jpg, png, or pdf of the Parent/Legal Guardian's Driver's License.(Required)

The parent or guardian has attached a copy of their driver’s license evidencing their signature on this form in lieu of additional witnesses.

Max. file size: 50 MB.

Comments

This field is for validation purposes and should be left unchanged.

FBC of Owensboro, Inc. Medical and Liability Release Form

First Baptist Owensboro

Worship Times