Student General Permission Form – Providence Baptist Church

Student General Permission

Student Name*

First Middle Last

Date of Birth*

Through this agreement, I give the Student listed above the right to go with the Providence Baptist Church Student Ministry on various events and outings from September 2023 through August 2024. These events and outings range from concerts and retreats to local recreational activities and mission projects. I realize that this is a general form to be placed on file in the Student Ministry's office. The Student Minister, staff, and volunteers will use the student's information in outreach and communication through out the year. I also understand that a separate registration form, which incorporates this Permission Form therein, will be needed for each overnight event to show that I have further consented for my student to travel with the Student Ministry of Providence Baptist Church.

Student Cell

Student Email

Current Grade*

School*

Home Address*

Street Address Address Line 2 City State ZIP Code

Contact Information

Parent/Guardian*

First Last

Cell Phone*

Email*

Parent/Guardian

First Last

Cell Phone

Emergency Contact Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Relationship*

Please describe the relationship to the student:*

Emergency Contact Name

First Last

Emergency Contact Phone

Relationship

Please describe the relationship to the student:*

Medical Information

Primary Doctor*

Doctor Office Phone*

Last Tetanus Shot*

Allergies & Medication*

Insurance Company*

Policy Holder's Name*

First Last

Policy Holder's Number*

Group Number*

Student Waiver as to Personal Property

My student and I understand that it is their responsibility to safeguard any personal property brought on any outing/event. We further understand that Providence Baptist Church will not be responsible under any circumstance for any property lost, misplaced, or stolen, either directly or indirectly. We also acknowledge and agree that Providence Baptist Church does not have any insurance coverage related to any such loss of our personal property.

INITIAL TO AGREEE*

Permission to Use Photo & Video

I grant Providence Baptist Church the right to take photographs and videos of me and my family while engaged in actives with the church. I authorize Providence Baptist Church, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Providence Baptist Church may use such photographs and videos of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

INITIAL TO AGREE

Permission to Medically Treat

If a medical emergency should arise while at the outing/event and I cannot be immediately contacted, I hereby give permission to Providence Baptist Student Ministry to select a physician and/or hospital for my child's care. I hereby also give the physician and/or hospital, as selected by Providence Baptist Student Ministry, my permission to hospitalize, medically treat, order injections, anesthetize, or perform surgery as medically necessary for my child, as reasonably determined and advised by proper medical personnel.

INITIAL TO AGREE

Parent or Legal Guardian Signature

Person who filled out this form*

First Last

Relationship to Student*