FBC Kids Registration Form

Child's Name:

Mailing Address:

Primary Phone Number:

Grade for 2021-2022:

School:

Parent(s)/Guardian(s) Full Name:

Mother/Guardian Phone Number:

Mother/Guardian Email:

Father/Guardian Phone Number:

Father/Guardian Email:

Do you use text messaging?

Dietary Allergies (gluten, dairy, nuts, etc):

Drug Allergies:

General Allergies:

Allergic to Bee Stings?

Special Health Problems, Concerns, and/or Instructions:

Insurance Company, Phone Number, Policy Number and Group Number:

Insurance Card: (Please attach a copy of the front and back of your insurance card):

Upload File

Physician / Phone Number / Address:

Dentist / Phone Number / Address:

Permissions: (By checking the boxes below, I certify that my child has permission to participate):

In all planned activities for FBC Kids

In playing on the playground at FBCSP

In church newsletter, television, or newspaper photographs

In photographs on the church website (no names used)

In photographs or videos on the church Facebook and Instagram

I understand that it is the expectation of First Baptist Church that my child will remain for the duration of the scheduled event unless they, or their parents, notify the adult leadership of the event

I understand that First Baptist Church does not carry accident or medical insurance on participation volunteers. I agree that my insurance company will be used for such medical care expenses. I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance and that I am responsible for the payment of any medical bills.

In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation with First Baptist Church, every reasonable effort will be made to contact the persons listed on the reverse side. If unsuccessful in contact the persons listed, consent/permission is give for treatment of competent medical personnel.

By typing my initials I acknowledge that all information I have included is accurate:

FBC Kids' Information and Medical Release Form

First Baptist Church
200 East New York Avenue, Southern Pines, NC 28387
(910) 692-8750, office@fbcsp.org

FBC Kids' Information and Medical Release Form

First Baptist Church200 East New York Avenue, Southern Pines, NC 28387(910) 692-8750, office@fbcsp.org

First Baptist Church
200 East New York Avenue, Southern Pines, NC 28387
(910) 692-8750, office@fbcsp.org