Students Permission Form 2 - Personal Information

ERBC Students Permission Form 2 - Personal Information

Use of Personal Information

Edwards Road Baptist Church is authorized to maintain the information below for use in future Student Ministry Activities. The Participant understands that if any of the information changes, the Participant must provide updated information to the Student Ministry Office.

Please provide us with a photocopy (front and back) of the Subscriber’s Insurance Card. If the Participant does not have Insurance coverage, they will need to purchase a temporary policy and provide a copy of the temporary card to the Student Ministry Office prior to participating in the Activity.

Students Form 2

Participant

Date of Birth

Address

City/State/Zip

Telephone

Email Address

Father's Name

Father's Cell/Home Phone

Father's Work Phone

Mother's Name

Mother's Cell/Home Phone

Mother's Work Phone

Emergency Contact

Emergency Contact Phone

Any known medical problems?

If yes, please explain

Any medicines to be taken daily?

If yes, please explain

Is Participant allergic to any drugs, medicines, plants, bee stings, milk, foods, etc.?

If yes, please explain

Name of Insurance Company

Contract or Group Number

Policy Number

Subscriber Name

Subscriber Date of Birth

Insurance Company Phone Number

Signature of Parent(s) or Legal Guardian(s) or, in the case of an adult participant, the Participant

Date

Be sure to press the "Submit" button to enable your information to be sent to ERBC.