Please list any special health conditions which FBC Greensburg should be aware of (such as allergies,
medications, medical conditions, etc.)_______________________________________________________
______________________________________________________________________________________
Please list any physical limitations or activities to which your student should not participate____________
______________________________________________________________________________________
Does your child know how to swim?
No
Yes
If yes:
Beginner
Intermediate
Advanced
Any other notes or information you would like FBC Greensburg to be aware of? _____________________
______________________________________________________________________________________
Health Insurance Provider__________________________ Policy#/Group#__________________________
Name of policy holder____________________________________________________________________
Date_________________
Printed Name_________________________________________________
Waiver of Publicity Form
I give permission for the use of any photos, movies, and audio or video tapings of my childs act
activities
ivities in
connection with First Baptist Church Greensburgs Youth Ministry, to be used with FBCs approval as they
see fit for promotional, educational, or religious purposes.
Signature_____________________________________________________
Date___________
Date_________________
Printed Name_________________________________________________
FOR NOTARY PURPOSES ONLY BELOW THIS LINE
STATE OF LOUISIANA
PARISH OF ______________
On this _____________ day of _________________________, 20____, before me personally appeared
_______
____________________________________________________,
_____________________________________________, to me known to be the person who executed the
foregoing instrument, and acknowledged that he/she executed the same as his/her free act and deed.
__________________________________
Notary, State of Louisiana
My Commission Expires: ____________________________