Parent Permission — First Baptist Church, Corbin Kentucky

2021-2022 Parent Permission & Info Update

New year, new permission! To honor your role as parent, FBC asks for you to fill out the following each year for all your students/children.

Student's Name

First Name

Last Name

Parent/Guardian 1

Grade

(If filled out during summer- list upcoming grade)

Any updated medical alerts, contact info, or recent moves?

(Note: If this is your first time filling out the parent permission form, please fill out the entire form)

Yes- Please update your family information below

No- Skip down to the "Parent Permissions" at the end

Family Information

Parent/Guardian 1- Phone

(###)

###

####

Parent/Guardian 2

Parent/Guardian 2- Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

YYYY

Medical Stuff

Does your Student have hospitalization insurance?

Yes

If yes, please list the name of your insurance provider and policy number:

Medications/Allergies

Please list any medications your child is taking or any food/drug allergies:

Student Needs

Any conditions/restrictions you would like us to be aware of for your child (i.e. asthma/rescue inhalers, limitations on physical play, accessibility & sensory needs, etc.)?

Parent Permissions

We like to capture memories

Do you give FBC of Corbin permission for your student’s picture/video to be taken and displayed?

Yes

General & Vehicle Permission/In Case of Emergency

By clicking SUBMIT you are agreeing to the following: General/Vehicle Permission- I, the parent/guardian(s) listed above, give permission for my student to attend FBC of Corbin sponsored events and activities for the listed ministry year. I additionally give permission for my student to ride in any vehicle designated by the adult in whose care the minor has been entrusted while participating in these activities. In Case of Emergency- I, the parent/guardian(s) listed above, authorize the adult, in whose care the minor has been entrusted, to consent to any x-ray, anesthetic, medical, surgical, or dental diagnosis, treatment, and/or hospital care, to be rendered under the general or special supervision and on the advice of any medical professional licensed under the Medical Practice Act whether such diagnosis or treatment is rendered at the office of said professional or at said hospital. I agree to be liable/pay all costs associated with any necessary treatment.