Parent/Legal Guardian *

First Name

Last Name

Parent/Legal Guardian Phone Number *

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Birthdate *

MM

DD

YYYY

Emergency Contact Phone Number *

(###)

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By clicking these checkboxes I agree that: *

I am the parent of the student whose information is on this form

I hereby release First Baptist Church Valley Mills and its directors, employees and volunteers from responsibility and liability for any injury or illness that my child may sustain during the Fields of Faith activities on Oct. 8th, 2025.

I voluntarily waive any claim against First Baptist Church Valley Mills, the volunteers, employees, and the owner/driver of the car or bus providing transportation to and from the Fields of Faith event.

In the event of an emergency, I hereby authorize an adult leader of these activities, as an agent for me, to consent to any x-ray examination, medical, dental, or surgical diagnosis, treatment and hospital care advised and supervised by a physician or surgeon

First Baptist Church Valley Mills has my permission to post pictures of my child(ren) via group pictures, videos, and other "digital media" to fbcvm.org and social media platforms(Facebook, Instagram, etc.).