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FIRST BAPTIST CHURCH AMARILLO
ADULT AUTHORIZATION FORM
January 2024 – December 2024
Name (First, Middle, Last)
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Cell Number
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Any other contact numbers:
Date of Birth (MM/DD/YYYY)
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ADDRESS (Street, City, State, Zip):
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Email
*
Any additional email addresses
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
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Relationship
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Main Phone Number
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Doctor's Name
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Doctors Phone Number
Very briefly, please list any medical/environmental allergies, medications being taken, medical problems or other pertinent information for this child. Please type NONE if none.
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0/80 characters
Chicken Pox
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YES
NO
Appendix removed
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YES
NO
Fainting spells
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YES
NO
Convulsions
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YES
NO
Asthma
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YES
NO
Diabetes
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YES
NO
Heart trouble
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YES
NO
Insect bite allergy?
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YES
NO
If YES, what insect?
Date of last Tetanus
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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.
Insurance Carrier
Group/Policy Number
Cardholder Name
Cardholder Date of Birth
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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, 2024 - December 31, 2024. 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.
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YES
I understand that entering my name below constitutes as my electronic signature.
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YES
Name
*
Date
*
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