Page 1 of 2 Baker First Baptist Church 3213 Groom Rd, Baker, LA 70714, 225-775-0520
Pastor: Bud Traylor Youth Minister: Amelia Pilcher
Medical Release From:
Please print in ink
Name: ___________________________________________________ Age ________ Birthday __________
LAST FIRST MIDDLE
Grade in school Male Female Email _______________________________
Address _______________________ City __________________ State _________ Zip ______________
Phone _________________________ cell ________________________
Medical insurance company ______________________________ Policy # _________________________________
Mother’s name ____________________________ Phone: Home ____________________ Work _________________
Father’s name _____________________________ Phone: Home ____________________ Work _________________
Emergency contact __________________________ Phone: Home ___________________ Work ________________
Physician ________________________________________Office phone __________________________________
Dentist __________________________________________Office phone __________________________________
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity,
weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be
aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it
to this form. Include names of medications and dosages that must be taken.
Check the following areas of concern for this student. If necessary, add another page with details:
1. For your child’s safety and our knowledge, is your student a
good swimmer fair swimmer non-swimmer
2. Does your child have allergies to
pollens medications food insect bites
3. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma epilepsy / seizure disorder heart trouble diabetes
frequently upset stomach physical handicap
4. Date of last tetanus shot:
5. Does your child wear glasses contact lenses
6. Please list and explain any major illnesses the child experienced during the last year:
Additional comments:
Should this child’s activities be restricted for any reason? Please explain:
Page 2 of 2
For your information, we expect each student to conform to these rules of conduct
No possession or use of alcohol, drugs, or tobacco
No students can drive
No fighting, weapons, fireworks, lighters, or explosives
No offensive or immodest clothing
No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
Participation with the group is expected
Respect property
Respect one another, staff, and adult leaders
Respect and comply with event schedules
Students who fail to comply with these expectations may be sent home at their parents’ expense.
I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth
group activities. I agree to abide by the stated personal limitations and code of conduct.
Student signature: ______________________________________________________ Date:________________
Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller-skating, roller -
blading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing,
snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: If you desire to limit your
child’s participation in any event, please submit your wishes in writing to the church youth pastor prior to that event.
This document also serves as a release for my child to appear in photographs and/or videotapes while participating in
activities and events.
________________________________ has my permission to attend all youth activities sponsored by Baker FBC
NAME OF STUDENT
from ____________________ to __________________.
DATE DATE
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church
and its staff of any liability against personal losses of named child.
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her
to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry
or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any
and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s
involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable
medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician
and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims,
demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately
responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health
insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and
will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child
home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Parent/guardian signature: ________________________________________________ Date: __________________