Family Information & Release Form

Parent / Guardian Name(s)

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home or Cell Phone

(###)

###

####

Home or Cell Phone 2

(###)

###

####

Work Phone

(###)

###

####

Parent / Guardian Email

CHILD INFORMATION

1. Child Name

First Name

Last Name

Birth Date

School / Grade

Gender

2. Child Name

First Name

Last Name

Birth Date

School / Grade

Gender

3. Child Name

First Name

Last Name

Birth Date

School / Grade

Gender

4. Child Name

First Name

Last Name

Birth Date

School / Grade

Gender

5. Child Name

First Name

Last Name

Birth Date

School / Grade

Gender

EMERGENCY CONTACT INFORMATION

Emergency Contact Name

First Name

Last Name

Relationship to family

Emergency Home or Cell

(###)

###

####

Emergency Phone (other)

(###)

###

####

Emergency Contact Email

MEDICAL INFORMATION & RELEASE

Insurance Carrier

Name of policy holder

Policy / group number

List all known medical conditions

List any important medications currently taking

List all known allergies (food, medicine, etc.)

Additional information to insure the proper care & safety of your child / children

I, the undersigned, have legal custody of the minor(s) listed on this form and have given my consent for him/her/them to attend events being organized by Liberty Bible Church. I understand that there are inherent risks involved in any ministry event, and I hereby release Liberty Bible Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s/children’s involvement. I affirm that the health insurance and medical information provided is accurate at this time. If this information changes, I will notify Liberty Bible Church as soon as possible. In the event that he/she/they is/are injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. I 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 my health insurance provider. Should it be necessary for my child/children to return home from an event due to either medical or disciplinary reasons, I will also assume all transportation costs. Checking "Yes" below is considered your digital signature for the purposes of this authorization. By checking here, you are consenting to the use of your digital signature in lieu of an original signature on paper. You have the right to request that you sign on a paper copy instead. By checking "Yes" below, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. Your agreement to use a digital signature with us will continue for the full duration of 2025 or until you notify us in writing that you no longer wish to use a digital signature.

Parent / Guardian Name

First Name

Last Name

Date Submitted

YYYY

Digital Signature

Yes

Multimedia Release

I, the undersigned, hereby authorize Liberty Bible Church to use photos or videos of my child/children on printed materials and digital platforms for informational and promotional purposes. Though the privacy of my child/children will be respected, photos or videos of my child/children shall remain the exclusive property of Liberty Bible Church and shall be used without notice or compensation. This authorization is required as we cannot guarantee that children will not inadvertently appear in photos or videos.

Parent / Guardian Name

First Name

Last Name

Date Submitted

YYYY

Digital Signature

Yes

Submission of this form indicates that you understand what is contained in this authorization. This authorization shall remain effective for the full duration of 2025 unless sooner revoked in writing by the parent or guardian.

If you would prefer a paper copy of this form, one can be obtained from the church office during business hours. You can also download the PDF file below. The PDF will need to be printed, filled out and submitted to the church office.

Medical Release PDF Download