STUDENT/PARTICIPANT - First, Middle & Last Name

Gender: Gender:MaleFemale

Birthdate:

Grade for 2025-26

School Child Attends:

Student's/Participant's Phone Number

Student's/Participant's Email

Street Address / City / ZIP

Covered by medical Insurance? Covered by medical Insurance?YesNo

Insurance Company Name and Policy/Group ID#

Are there any allergies or medical conditions of which we need to be aware? If so, please specify:

Prescriptions or Medicines

If needed, do you authorize giving pain medication (ex. Tylenol or Advil) to your student/participant? If needed, do you authorize giving pain medication (ex. Tylenol or Advil) to your student/participant?YesNo

Name of Parent / Guardian

Parent/Guardian Phone Number:

Parent/Guardian Email Address:

Name of Parent / Guardian 2

Parent/Guardian 2 Phone Number:

Parent/Guardian 2 Email Address:

Name of Emergency Contact (if Parent/Guardian cannot be reached)

Relationship of Emergency Contact to Student/Participant

Emergency Contact's Phone Number

Do you give permission to have your student's/participant's picture taken for BBC Students events, print, church website, church videos and/or social media? Do you give permission to have your student's/participant's picture taken for BBC Students events, print, church website, church videos and/or social media?YesNo

By completing this form you attest that the information on the form is true and accurate to the best of your knowledge and that the parent/guardian and student/participant have read the "Annual Permission / Consent and Liability Release". By completing this form you attest that the information on the form is true and accurate to the best of your knowledge and that the parent/guardian and student/participant have read the "Annual Permission / Consent and Liability Release". We agree with the above statement.

Please type Parent/Guardian name:

Please type Student/Participant name:

Today's Date