EVENT NAME ____________________

DATE OF ACTIVITY ____________________

STUDENT INFORMATION Youth’s Name: _____________________________________

Phone: _____________________ Birth Date: _________________

School: _______________________ Grade: _____________________

IF VISITOR AND/OR NEWCOMER Address: _____________________________________

_____________________________________

Current Church: ________________________________________________

Guest Of: ___________________________

This is to certify that the youth named above has my permission to go with 2nd Baptist Church to the above listed activity.

AUTHORIZATION FOR EMERGENCY TREATMENT

I hereby authorize any physician, surgeon, or dentist so chosen by a sponsor of 2nd Baptist Church, Greenville KY, to administer any emergency treatment, procedure, or medicine necessary or advisable when church sponsors accompany the youth named about to an emergency room of any hospital or clinic. I also authorize church sponsors to secure the use of an ambulance if necessary for transporting my child to the hospital or clinic. I further agree to pay the hospital, doctors, and ambulance service for all services rendered to the above named person.

Signed: ______________________________________________

Parent or Guardian

Telephone number___________________________________

Please list below all allergies and other information we should know (medicines he/she will have with him/her, reaction to insect bites, etc.):

______________________________________________________________________________________________________

If you are going out of town, how may we contact you or whom may we contact? ____________________________________________________

If you would like, include the name of your insurance company and identification number: __________________________________________

________________________________________________________________