Minor Consent and Medical Forms
First / Last name of Participant
Date of birth
MM
/
DD
/
YYYY
Gender
Male
Female
Grade
Primary Phone number
Secondary Phone number
Address
Email address
FBS Activity (ies)
Preschool (Birth - 5yrs)
Children's (1st - 5th)
Students (6th - 12th)
Adult Ministries
Recreation
P139
Guest Services
Other:
Emergency Contact (Parent/Guardian)
First / Last name
Address
Phone number
Second Emergency Contact (Parent/Guardian)
First / Last name
Address
Phone number
Medical Authorization and Release
I understand that FBS will make reasonable efforts to contact Participant’s above listed Emergency Contacts in the event of a medical emergency. Nevertheless, I hereby give permission and authorize the applicable staff, volunteers, and agents of FBS to provide, facilitate, and consent to the provision of any first aid, doctor’s care, hospitalization, surgery, transportation to medical facility, and/or any other form of medical care or treatment that they deem necessary because of illness, injury, or other health problems that Participant may suffer while participating in the Activities. I agree to be financially responsible for any medical bills incurred as a result of medical treatment for Participant. I agree to release and hold harmless FBS and its employees, volunteers, directors, officers, other agents, and any agencies it works in conjunction with, from any claims, liabilities, actions, demands, or losses for or from bodily injury, property damage, or otherwise, which may arise from provision or omission of any type of medical care or transportation to or from a treatment facility by those chosen by FBS to administer medical care for and/or transport Participant, and which may arise by any cause, including through the negligence or carelessness of FBS, its agents, or any agencies working in conjunction with them. I understand that all reasonable safety precautions will be taken at all times by FBS and its representatives during the Activities.
Medical Information
Current Medication(s) and dosage
Known Allergies
Insurance Carrier
Insurance Policy Number
Any physical, emotional, or mental conditions of Participant of which FBS should be aware (this information is strictly confidential)
Please check the following medications that you give permission for the Participant to take should they be needed:
Ibuprofen - for pain or fever
Acetaminophen - for pain
Tums, Mylanta, Maalox - for upset stomach
Dramanine - nausea prevention
Benadryl - allergic reactions or cold symptoms
Zofran - for excessive vomitting
Murine Eye Drops - for irritated eyes
Aloe-Vera - Sunburn
Bactine - an antiseptic/antibiotic cleansing agent
Triple Antibiotic Cream - to prevent infection
Anti-diarrheal
Hydrocortisone
None
Date of Last Tetanus Shot
MM
/
DD
/
YYYY
Additional Medical Information
I acknowledge that FBS may offer me an optional insurance policy and that, if offered, such optional policy is the only medical insurance coverage available (outside of my own medical insurance coverage) for any accidents that occur while participating in the Activities. If offered, this policy is available for a fee in addition to those fees already associated with the Activities.
Terms of Service
I agree to the
terms of service
.
Parent/Guardian Signature
Clear
Date
MM
/
DD
/
YYYY
Please Print Participant's Name
Relationship to Participant
Verification
SUBMIT FORM
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