Event Release Form-Parental/Guardian Consent

For a student to attend an Event with FBSM or FBC-CM event offsite we need a consent form for that specific event, and a medical form on file.  Please print this form out and fill it out specifically for the event you plan to attend.  Event specifics will be listed on our website, or the FBSM First Baptist Student Ministries Minonk, IL FaceBook Page _________________________________________________________________


Location of Activity:____________________________

Activity may include:___________________________

Date of Activity:_________________ Time of Activity: ________________

Child’s name___________________________________ Age _________

Parent’s name __________________Emergency Phone Number _________________
Special Information
My child: (check applicable boxes)
__ has no existing medical conditions that would endanger him/her from participating.
__ has a medical condition that is being treated and poses no danger to his/her participation.
__ is taking prescribed medication(s): ____________________________________________________
__ other: ___________________________________________________________________________
Special boundaries for this trip:
We are asking that all students abide by these special boundaries for this trip:

1.)  No student will go anywhere alone

2.)  No student will go anywhere without an adult.

3.)  Students will travel in groups of 5 or more, including an adult once at the event.

By signing below, the parent/guardian gives consent to the said child to participate in a church sponsored activity. The undersigned agrees to hold harmless (which means to not assign blame or legal responsibility) the First Baptist Church of Minonk, IL, its officials and those workers assisting in the activity from any and all harm that may be sustained as a result of or during the activity, including transportation to and from the activity. Parent/Guardian further agrees to resolve any dispute arising from any harm where the matter is, by mutual consent, deemed not covered by this consent or over the consent itself, by submission to binding arbitration.

Signature: ____________________________Date__________________