Is this for the Senior High trip or the Junior High trip?* Senior High Junior High
Student Name*
Student Name 2
Student Phone (if applicable)( ) -
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
As the parent / guardian of the above named child, I give him / her permission to participate in the First Baptist Church Andalusia Youth Summer Retreat.*
Parent/Guardian Name
I release the church and its representatives from any liability in the event of an accident enroute, during, or returning from an activity. I also authorize them to obtain any emergency medical attention that may be required during my child’s attendance.*
Parent Name
Date* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2023 2022
Parent/Guardian Phone*( ) -
Are there any specific or special medical needs that we should be aware of for your child? Please list them below along with any information that could be helpful.
Secondary Emergency Contact (other than the above parent/guardian)*
Name
Secondary Emergency Contact Number*( ) -
