Faith Bible Church - Oregon

Child's First Name

Child's Last Name

Names of Additional Children

Grade Level (If signing up multiple children include name and grade followed by a comma and then the name and grade of another child, etc.)

School

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Email Address

Address 1

Address 2

City

State

Zip/Postal Code

By submitting this form I hereby give permission for my child/children to participate in events and outreach with Faith Bible Church Youth Group. I understand that every reasonable measure of supervision will be taken to safeguard the health/safety of my child during the event, in the event that my child is injured or becomes ill while participating in an activity, I will be notified as soon as possible. In the unfortunate event of sickness or accident, I agree to indemnify and hold harmless Faith Bible Church, 5750 North Highway 101, Otis, Oregon, and any personnel including but not limited to pastors, leaders, chaperones, and the drivers who are involved for all claims arising as a result of my child's participation in this activity.

IN THE EVENT OF AN EMERGENCY I authorize the leader(s) to arrange and procure transportation to their chosen physician who, in turn, may hospitalize, secure proper treatment for, and order injections, anesthesia, or surgery for my child according to their best judgement.

Name of Insurance Provider

Insurance Phone Number

Is your child presently on medication?
Yes
No

If yes, please list:

Does your child have any drug sensitivities?

FBC Youth
Annual Consent Form

Contact Info

FBC YouthAnnual Consent Form

FBC Youth
Annual Consent Form