Permission/Medical

First Baptist Church Youth Permission / Medical Form

All students are required to have the following document on file in the church office to participate in a church function, activity, or trip. Please fill this out completely and attach a copy of the front and back of your insurance card in an email to rob@firstmoultrie.org. Thank you!

Youth Permission/Medical Form

"*" indicates required fields

Child's Name*

First Last

Gender*

Age

Current Grade*

Date of Birth*

School Your Child Attends

Shirt Size*

Address*

Street Address Address Line 2 City State ZIP Code

Physical Address if Different from Mailing Address

Street Address Address Line 2 City State ZIP Code

Mother's Name*

First Last

Mother's Email

Mother's Cell Phone

Mother's Home Phone

Father's Name*

First Last

Father's Email

Father's Cell Phone

Father's Home Phone

Emergency Contact*

First Last

Relationship to Child*

Emergency Contact Cell Phone*

Emergency Contact Home Phone

My Child Does NOT Have Insurance

Medical History*

Include special medical needs or concerns such as asthma, allergies, conditions, dietary needs, medications, etc.

Name

This field is for validation purposes and should be left unchanged.

First Baptist Church Youth Permission / Medical Form

Youth Permission/Medical Form

First Baptist Church Moultrie

Sunday Services

Wednesday Services