Love, Joy, Peace...

I give permission to Plains Baptist Church and it's representatives to make whatever emergency (e.g., first aid, disaster evacuation) measures are judged necessary for the care and protection of my child while under the supervision of Plains Baptist Church. In cases of a medical emergency, I understand that my child will be transported to the nearest emergency room by the local emergency unit for treatment if the local emergency resource (police, fire, rescue squad) deems it necessary. It is understood that in some medical situations the staff will need to contact the local emergency resource before the parent, child’s physician, or other adult acting on the parent's behalf.

Name (Required)
Email Address (Required)
Child's Full Name (Required)
Drug Allergies / Special Medical Needs: (Required)
Chronic Disease / Other Health Problems: (Required)
Name of Insurance Coverage: (Required)
Insurance Policy Number:
Emergency Contact Name (Required)
Emergency Contact Phone Number (Required)
I give permission to Plains Baptist Church and it's representatives to make whatever emergency (e.g., first aid, disaster evacuation) measures are judged necessary for the care and protection of my child while under the supervision of Plains Baptist Church (Required)
Your typed name represents your binding signature. Parent or Guardian's Full Name:
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