FBC Kids' Medical Release

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Email *

Child's First Name: *

Child's Last Name: *

Gender: *

Male

Female

Grade: *

Kindergarten

1st

2nd

3rd

4th

5th

Child's Birthdate: *

YYYY

Child's T-shirt Size: *

Child Small

Child Medium

Child Large

Adult Small

Adult Medium

Adult Large

Adult XL

Other:

Required

Parent or Guardian Name(s): *

Parent or Guardian Cell (with area code)#: *

Mailing Address/City/Zipcode: *

Emergency Contact Name: *

Emergency Contact Cell (with area code)#: *

Secondary Contact Name (not immediate family member):

Secondary Contact Cell (with area code)#:

Please list any allergies or write NONE: *

Physical restrictions? Please describe or write NONE: *

Medical Dr. Name:

Medical Dr. Phone #

Insurance Company:

Insurance Address:

Name of Insured:

Insurance Policy Number:

Medications/dosage/time of day or write NONE: *

Swimming: *

Non-Swimmer

Fair Swimmer

Good Swimmer

E-SIGN BY TYPING YOUR NAME BELOW: I am the parent and/or guardian of the minor above. I give permission to travel/participate in church sponsored events and functions of FBC Children's Ministry, Snyder, TX. In the event there arises an emergency requiring medical or surgical attention, I consent and give permission to FBC Children's Ministry, Snyder, TX, and its representatives, or any attending physician to make such decisions and to perform medical or surgical treatment upon the minor, which in their sole discretion, may be reasonable and necessary under the circumstances. I, the parent and/or guardian of the minor, do release, acquit, discharge, and covenant to hold harmless the FBC Children's Ministry, Snyder, TX or its representatives from any and all actions, damages, and/or liabilities arising out the treatment of any sickness or accident incurred by the minor. It is the intention of this release that FBC Children's Ministry, Snyder, TX and its representatives incur no liability whatsoever while attending to the reasonable and necessary treatments, surgery and other medical needs that may, in their sole discretion, be needed by the minor. *E-SIGN BY TYPING YOUR FIRST and LAST NAME BELOW *

Website, Social Media, Publication, Video, and Photo Release. In an effort to be conscientious about online privacy, we are requesting photo releases to promote and share church functions and activities. Students generally will not be identified in photos. However, please understand that others outside the church staff may tag your child. If there is ever a problem, please contact Kasey Walker any time. *

Yes, allow FBC Snyder, TX to post images/videos of my child on the church website, Children's Ministry page, social media, or in church publications.

No, my child's picture will not be taken, published, or shared. My child will not be in group/activity pictures and videos.

Required

Exposure to COVID-19, and other illnesses, is an inherent risk in any public location where people are present; we cannot guarantee your child will not be exposed to any illnesses. Any child with symptoms or illness should not attend church events. This preventative action will be what is best for everyone. If you have any questions, please feel free to contact Kasey Walker. E-SIGN BY TYPING YOUR NAME BELOW: I understand the risks involved in having my child attend FBC Kids' activities on campus and off campus. I understand there is a risk in any public gathering. I will not hold FBC Snyder liable in the case that my child should come in contact with COVID-19 or other illnesses while attending church activities on campus or off. *

Please share any additional information about your child that his/her teachers at church need to know.

A copy of your responses will be emailed to the address you provided.

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