FELLOWSHIP BIBLE CHURCH CROSSCHECK/GEMS/YOUTH MINISTRIESREGISTRATION, RELEASE AND EMERGENCY MEDICAL FORM

13021 Worthington RoadPhiladelphia, PA 19116

(267) 388-5958

This form will be maintained on file at the Church office for one year. An additional Permission Slip may be required for any potential overnight outings.

I/we give permission for ______________________________ to participate in all Fellowship Bible Church-sponsored trips and activities away from the Churchs campus throughout the current calendar year. I/we have reviewed the rules of the activities; am aware of the nature and purpose of the trips and activities; and understand the risks involved in those activities. I/we further understand that I/we may revoke permission for a specific trip or activity by written notice to the Church.

I/we understand that there are risks involved with participation in off-campus trips and their associated activities. In consideration of my child being allowed to participate in the trip, I/we agree to assume responsibility for those risks associated with the travel and activities. I/we agree to hold harmless Fellowship Bible Church, its employees and representatives, including volunteers and other drivers, from any and all claims arising from my childs participation. This Release does not apply to claims of intentional misconduct or gross negligence by the Church, its employees, representatives or volunteers.

In case of accident, illness or other emergency, I/we request that the Church contact me/us. If the Church cannot reach me/us after conscientious effort, I/we give permission for the Church staff to call paramedics or any licensed medical provider, as deemed necessary and appropriate. If a life-threatening emergency exists, I/we give permission for Church staff to call paramedics or emergency personnel immediately, and then contact me/us as soon as possible thereafter.

I/we authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care which in the best judgment of the medical personnel is deemed advisable. I/we agree to assume the financial responsibility for expenses incurred as a result of those services being provided. I/we also agree to be financially responsible for needed emergency medical transportation.

I/we also give permission to Fellowship Bible Church to take pictures, video recordings and audio recordings of the above-mentioned child at church related events and use material on our church website and other promotional material for the church.

Father/Guardians Signature: Mother/Guardians Signature:

____________________________Date:_________ _____________________________Date:_______

Name Printed:______________________________ Name Printed:_____________________________

TURN OVER TO COMPLETE FORM

FELLOWSHIP BIBLE CHURCH CROSSCHECK/GEM/YOUTH MINISTRIESREGISTRATION, RELEASE AND EMERGENCY MEDICAL FORM

13021 Worthington RoadPhiladelphia, PA 19116

(267) 388-5958

NAME OF PARTICIPANT:___________________________________________________________ADDRESS: STREET:________________________________________________________________

CITY:______________________STATE:____________ ZIP:______________DOB:__________________ AGE:_________ GRADE _______________________

PARENT(S)/GUARDIAN(S)/SPOUSE:__________________________________________________PARENT/GUARDIAN/SPOUSE E-MAIL:_______________________________________________EMERGENCY CONTACT PHONE NUMBERS:(home)_______________________________ (work)________________________________________(cell-Mom/Wife)_____________________ (cell-Dad/Husband)_______________________________

PHYSICIAN:_____________________________________ PHONE:__________________________

PLEASE LIST ANY:Allergies (food, medicine, bees, lactose):___________________________________________________________________________________________________________________________________Existing medical conditions (e.g. asthma, seasonal allergies, etc.):_______________________________________________________________________________________________________________Required medications (specific dosages/diagnosis please):_______________________________________________________________________________________________________________________________________________________________________________________________________DATE OF LAST TETANUS SHOT:____________________________________________________

PERMISSION TO ADMINISTER IF NEEDED (Please initial): ALL__________________________

If ALL ARE NOT PERMITTED please initial individual permission:

Acetaminophen(Tylenol)____________AntiMotionSickness(Dramamine)______________________

Ibuprofen(Motrin/Advil)____________Hydrogen Peroxide__________________________________

Antacid(Tums/Maalox)_____________Triple Antibiotic Ointment/Bacitracin___________________

Throat Lozenge___________________Caladryl/Benadryl/Hydrocortisone Cream________________

Diphenhydramine(Benadryl)_________Sting Kill Swabs____________________________________

Eye Solution(Visine)_______________OraGel/Orabase_____________________________________

Sun Tan Lotion____________________Burn Cream(Solarcaine)/First Aid Cream________________

Petroleum Jelly____________________

Other:__________________________________________________