Partnering With Parents To Make Disciples

Mark Your Calendars

This Summer 2019

FUGE Union University in Jackson, Tennessee June 3rd - 8th
$60 Deposit Was Due Wednesday January 30th
(After Deposit) $115 Due May 8th

Current Wednesday Night Series

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Weekly Schedule

Sunday Mornings

9:15a - FBC Underground 7th - 8th Grade Sunday School
9:15a - FBC Underground High School Sunday School

Sunday Evenings

See Student Calendar below for specific dates.
5:30p - FBC Underground - 7th - 12th Grade Small Group
5:30p - FBC Room 202 - High School Small Group

Wednesday Evenings

6:30p - The Underground - 7th - 8th Grade Bible Study (Doors open at 6:00p)
7:30p - The Underground - High School Bible Study
Summer Months - 6:30p - The Underground - FUSE (7th-12th grade combined)

Get Connected - Stay Informed

Remind App

Student Release Form

Participant Name *

Participant Name

First Name

Last Name

Male

Female

T-shirt Size *

Age *

Date of Birth *

Date of Birth

YYYY

Current School Grade *

(During Summer - Grade Completed)

List of Any Known Allergies. *

(Medications and Substances)

List Any Special Dietary Needs. *

Date of Last Tetanus Immunization *

Date of Last Tetanus Immunization

YYYY

Current Prescription Medications *

Name and Dosage

Other Health Information *

Previous operations, serious illnesses, or any pertinent information about the participant's health.

Family Physician *

Family Physician Phone *

Family Physician Phone

(###)

###

####

Insurance Company *

Insurance Policy Number *

Parent/Guardian - Emergency Contact *

Parent/Guardian - Emergency Contact

Students under 18 years of age require parent/Legal Guardian. ALL STUDENTS must give an Emergency Contact.

First Name

Last Name

Parent/Guardian - Emergency Contact Phone *

Parent/Guardian - Emergency Contact Phone

(###)

###

####

Legal Guardian Acknowledgement *

The Participant listed above has my permission to attend any events or activities sponsored by the First Baptist Church of Chillicothe and its Youth Ministry Department within the dates of 8/01/2018 and 8/01/2019. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases First Baptist Church of Chillicothe, and its staff and/or volunteer leaders of any liabilities against personal losses of named participant. In checking the box below, and entering my name as the Legal Guardian I am stating that I, have legal custody of the participant named above, a minor, and have given our consent for him/her to attend events being organized by First Baptist Church of Chillicothe’s Student Ministry Department. I understand that there are inherent risks involved in any ministry activity or athletic event and, I hereby release First Baptist Church of Chillicothe, its pastors, employees, agents, and/or volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of this participant’s involvement. In the event that he/she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by First Baptist Church of Chillicothe, I agree to hold such person(s) free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate at this date, and will, to the best of my knowledge, still be in force for the participant named above. I also agree to bring this participant home at my own expense should they become Ill, or if deemed necessary by the Student Ministry staff.

I understand the disclaimer above.

Legal Guardian *

Legal Guardian

First Name

Last Name

Student Calendar

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Travis Smith

Email Travis