Youth Permission Form

FIRST BAPTIST CHURCH AMARILLO
YOUTH MINISTRY AUTHORIZATION FORM
January 2023 – December 2023

Please fill out for one child at a time, please do not put multiple children on one submission.

We must have an individual form on file for each child.

Thank you.

Student Name (First, Middle, Last) *

Student Cell Number *

Date of Birth (MM/DD/YYYY) * +

Grade (2022-2023 School Year) *

Gender *

Male

Female

Parent Name *

Parent Cell Number *

Address (Street, City, State, Zip) *

Second Parent Name

Cell Number

EMERGENCY CONTACT INFORMATION:

In case of emergency, we will always try to contact parents first. Please provide an alternate emergency contact in the event we cannot reach you.

Name *

Relationship *

Main Phone Number *

Other Phone Number

Doctor's Name *

Doctor's Phone Number *

Please list all medical/environmental allergies, medications being taken, medical problems or other pertinent information for this child. Please type NONE if none. *

Chicken Pox *

YES

Appendix removed *

YES

Fainting spells *

YES

Convulsions *

YES

Asthma *

YES

Diabetes *

YES

Heart trouble *

YES

Insect bite allergy? *

YES

If YES, what insect?

Please list any food allergies. Please type NONE if there are no food allergies. *

Please list any special conditions, restrictions, etc. that you would like us to be aware of.

I would like to upload an image of my student's insurance card *

YES

PLEASE UPLOAD AN IMAGE OF YOUR INSURANCE CARD. YOU MAY TAKE A PICTURE OR SCAN AND UPLOAD. PLEASE INCLUDE THE FRONT AND THE BACK OF THE INSURANCE CARD. PLEASE BE AWARE, THE FILES MAY NOT EXCEED 5MB TOTAL OR THEY WILL NOT ATTACH. IF YOU ARE UNSURE OF THE FILE SIZES, PLEASE FILL OUT THE INSURANCE INFORMATION INSTEAD OF ATTACHING.

Should you choose not to upload an image of your insurance card, please fill out the required insurace information below.

Insurance Carrier

Group/Policy Number

Cardholder Name

Cardholder Date of Birth +

I grant permission for any other adult, affiliated with First Baptist Church of Amarillo (over the age of 21), to seek necessary medical attention on my behalf. This permission is effective for one year from
January 1, 2023 - December 31, 2023. I hereby release and forever discharge all other adults, affiliated with FBC Amarillo and of First Baptist Church, Amarillo, from all claims, demands, actions, or causes
of action, past, present or future, arising out of any damage or injury while participating with
FBC Amarillo.

I give permission to publish pictures of my child in the Reporter or with the local media.

I give permission for my child to participate in field trips after being notified of the specific event.

I understand that entering my name below constitutes as my electronic signature. *

YES

Name *

Parent Email Address *

Additional Email Address

Date * +