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) First Last Age(Required) Date of Birth(Required) Month Day Year Address(Required) Street Address City State ZIP / Postal Code Emergency Contact(Required) First Last Emergency Contact Phone(Required)Family Doctor Family Doctor's PhoneHealth HistoryCheck all that apply. Allergies Insect Stings Drugs Other Explain 'Other'Other Conditions Heart Conditions Frequent Colds Diabetes Chronic Asthma Frequent Upset Stomach Hay Fever Epilepsy Physical Handicap If you checked any of the above, please give details.(i.e. include normal treatment of allergic reactions)Any Swimming Restrictions: Yes No Any Activity Restrictions: Yes No Explain restrictions:Also list the names and dosage of current medications.Insurance Company NameOur 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 Consent(Required) I agree to the Emergency Procedure and the Liability Release.EMERGENCY PROCEDURE: In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary. LIABILITY RELEASE: Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By submitting a photo of your government issued identification and this form in its entirety, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold this church or its employees or volunteer assistants or its individual members liable for damages or injuries to the person or property undersigned. The parents or guardians understand that they are submitting for the minor listed on this form, and the submission is for both a medical and liability release.Today's Date(Required) Month Day Year 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.NameThis field is for validation purposes and should be left unchanged.