FIRST BAPTIST CHURCH VALLEY MILLS

302 AVE . C, VALLEY MILLS, TX 76689 254-932-6273

CONSENT & RELEASE FROM LIABILITY & MEDICAL CONSENT FORM 

(DISCIPLE NOW 2025)

_______________________________ has my permission to participate in all activities of First Baptist Church Valley Mills and to be transported by church bus or private car when necessary. I understand that all events will have adult supervision. In consideration of the benefits to be derived from these activities, I hereby voluntarily waive any claim against First Baptist Church Valley Mills, its employees, volunteers, or sponsors. I also hereby voluntarily waive any claim against the owner/ driver of the car or bus furnishing transportation to any event.  I further agree to direct my son/daughter to conform to the fullest with the directions and instructions of the sponsors in charge.

In the event that my child becomes ill or sustains an injury while at an authorized and chaperoned event with First Baptist Church Valley Mills, I, the undersigned, give my permission to those in charge to take whatever steps necessary to stop any bleeding and to administer first aid.

I also consent to an x-ray examination, anesthetic, medical(or dental) or surgical diagnosis and treatment and hospital care, and the administration of drugs or medicine to be rendered to my child under the general or specialized supervisor and upon the advice of a duly licensed physician or surgeon.

This consent and release is in effect from the date signed. I understand that a copy of this form is as valid as the original. 

Parent/Guardian signature:  ____________________________________   Date: ____________

Street Address: _______________________________________     City:___________________

State: ___________   Zip Code: ___________   Email:__________________________________

Phone: _______________________   Work Phone: __________________________

Individual Health Information

Name: __________________________________         Date of Birth ____/____/______

Weight: __________      Height:___________    

Describe any health problems: ____________________________________________________

______________________________________________________________________________

Any Medications: Yes ___  No___ If yes, names of drugs and dosages:____________________

______________________________________________________________________________

Allergic to any medications: Yes___ No___  If yes, please list:____________________________

______________________________________________________________________________

Physician’s name:________________________  Office Phone:___________________________

Address:_____________________________________________

Name of Medical Insurance Company:_____________________________________________

Phone:_______________________________  Policy Number: _________________________

Group Number: _______________________________