Youth Group Permission Slip – First Baptist Church

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The undersigned does hereby give permission for our (my) son/daughter to attend and participate in First Baptist Church of Pikeville Youth Group, Lock-in, at First Baptist Church, 106 Cumberland Ave, Pikeville, TN 37367 on March 28th & 29th, 2025 6:00 pm to 9:00 am. I also give permission for our (my) son/daughter to participate in youth group activities on or off church grounds. The undersigned does also hereby give permission for our (my) son/daughter to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by First Baptist Church of Pikeville, Tennessee Youth Group. We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practice Act on the Medical staff of a licensed hospital and/or emergency care facility, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. We (I) do herewith authorize the treatment by this authority and is granted only after a reasonable effort has been made to reach us/me the parent(s) and/or guardian(s). We (I) the undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. My signature also serves to indicate my willingness to take full financial responsibility for any and all medical services rendered for the named participant. My signature also serves to indicate my willingness for my Health Insurance Company to be billed for any and all fees and services should they be needed.

We (I) hereby release First Baptist Church of Pikeville, Tennessee Youth Group, pastor, teachers, workers from this liability.

Health Insurance Company Name

Policy Number

Teens Name

Birthdate

Address

Parent's/Guardian Names

Parent's/Guardian Phone Number

Family Doctor

Doctor's Phone Number

Date of last tetanus shot

List any specific medical allergies

Such as bee stings, food, dye or drug allergies. Also list any medical conditions, illnesses or medications a physician would need to know:

Please add below at least one other emergency contact (other than those listed above) such as grandparents, aunts, uncles, neighbors and cell phone numbers:

1. Emergency Contact Name

1. Emergency Contact Phone Number

2. Emergency Contact Name

2. Emergency Contact Phone Number

3. Emergency Contact Name

3. Emergency Contact Phone Number

List last Phone

We (I) the parent(s) or guardian(s) of the aforementioned child do hereby acknowledge that the above information is true

and give permission for above treatment to be rendered and do not hold the aforementioned parties liable.

Parent's/Guardian Initials

These initials serve as the parent(s)/guardian(s) acknowledgment and consent to the terms of this document.