FIRST BAPTIST CHURCH LEXINGTON, TN

MEDICAL/TRANSPORTATION RELEASE FORM

Student’s Name __________________________________________________________

Parent/Guardian Name(s) __________________________________________________
Address ________________________________________________________________
________________________________________________________________
Student Date of Birth __________________________
Home Phone # ____________________ Parent/Guardian Cell # __________________
Parent/Guardian’s Employer ________________________________________________
Parent/Guardian Work Phone # ______________________________________________

Alternate Emergency Contact if Parent/Guardian cannot be reached:

Name __________________________________________________________________
Relationship to student _____________________________________________________
Phone # ____________________________ Cell # ______________________________

Physician/Hospital Preference Information:

Physician of First Choice ___________________________________________________
Phone # of Physician/Clinic _________________________________________________
Preferred Hospital ________________________________________________________

If the parents, guardians, and/or physicians listed above cannot be reached at the time of
an emergency, and if immediate observation or treatment is urgent in the judgment of
First Baptist Church Lexington (FBC) staff/volunteers, I authorize and direct the FBC
staff/volunteers to send my student to the hospital or doctor most easily accessible and for
such doctor to render such observation and treatment as immediately as necessary.

_______________________________________ ______________
Parent/Guardian Signature of Authorization Date

*Please turn over and complete reverse side of this form*

List all allergies (medication, food, and others) associated with your student:

________________________________________________________________________

List any medications (prescription and OTC) your student takes regularly:

Drug name Dose Frequency/Times Special Instructions

In circumstances involving the need of over the counter(OTC) medicine, I hereby grant
permission to have FBC staff/volunteers administer the dosage recommended on the label
of any necessary OTC drugs except:
_______________________________________________________________________

Insurance Information:
Medical Insurance Company/Provider ________________________________________
Primary policy Holder’s Name______________________________________________
Group/Policy # __________________________________________________________

I give permission for my child to attend events with First Baptist Church Lexington. I
also give permission for my student to be transported to/from FBC and other special
events during the year by the FBC buses and staff/volunteer/church member vehicles. In
addition, I understand that FBC staff/volunteers reserve the right to dismiss any student
whose influence and conduct becomes in any way detrimental to the best interests of
other members. I expressly covenant and agree not to sue FBC Lexington, its ministers,
staff, employees, volunteers, or members for any injury or damage of any kind that may
occur as a result of the ministry. I realize that FBC Lexington reserves the right to use
pictures and/or video of my students taken at events for future promotional and
informational purposes.

_______________________________________ ______________
Parent/Guardian Signature of Authorization Date