Medical Liability

FBC of Owensboro, Inc. Medical and Liability Release Form

THIS FORM IS VALID FOR ONE YEAR FROM THE DATE OF SIGNATURE. First Baptist Church • 230 JR Miller Blvd. • Owensboro, KY, 42303 • Phone: 270.683.3505 • Fax: 270.683.8067
Child's Name(Required)
Date of Birth(Required)
Address(Required)
Emergency Contact(Required)
Health History
Check all that apply.
Other Conditions
(i.e. include normal treatment of allergic reactions)
Any Swimming Restrictions:
Any Activity 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.
Address
Consent(Required)
Today's Date(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.
This field is for validation purposes and should be left unchanged.