Participant's Name or Family Name (if applicable)    Email:

Street/Apt. #    City    State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip

Age/DOB     Home Phone     Cell Phone

ICE(In Case of Emergency) Information required for all participants. If a Minor, Please list someone other than parents or guardian & complete the next section.

Name    Phone    Relationship to participant

Please Complete this section for MINORS only.

Father's Name Cell Phone    Father's Place of Employment Phone Number    Mother's Name Cell Phone    Mother's Place of Employment Phone Number

I authorize FBC Russellville through its trustees, officers, directors, employees, agents or representatives to render or obtain such emergency medical care or treatment for me as may be necessary should any injury, harm or accident occur to me while participating in church sponsored activities. *Please type in your name as an electronic signature for approval.* Participant Signature:    Date: ***For MINORS only: As the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for the care and protection of my minor child / student while under FBC Russellville's supervision. In case of accident or illness, I understand that my student will be taken to an appropriate medical facility for treatment. I understand that efforts will be made to contact me prior to treatment but in the event I cannot be reached in an emergency, I give permission to the church representative to make the decisions necessary for treatment. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. *Please type in your name as an electronic signature for approval.* Parent/Guardian Signature:    Date:

Participant Information If more than one member of your family is participating in this trip / event, please complete the section below by listing the requested information for each family member.

PARTICIPANT NAME	Age & DOB	Allergies?	Medications?	Health Conditions?	Date of last tetanus	Insurance? Please complete box at the bottom of page
1.		... Yes No	... Yes No	... Yes No		... Yes No
2.		... Yes No	... Yes No	... Yes No		... Yes No
3.		... Yes No	... Yes No	... Yes No		... Yes No
4.		... Yes No	... Yes No	... Yes No		... Yes No
5.		... Yes No	... Yes No	... Yes No		... Yes No
6.		... Yes No	... Yes No	... Yes No		... Yes No
7.		... Yes No	... Yes No	... Yes No		... Yes No
8.		... Yes No	... Yes No	... Yes No		... Yes No

If you selected "Yes" for any of the above questions, please give details in the space below. Please use the numbers on each line when referencing further details below.

INSURANCE INFORMATION

Policyholder's name    Primary Insurance Policy No:    Group No:    Provider (BCBS, AETNA,etc.)