Teen Yearly Permission Form

Student Information

Student Name

Address

Date of Birth

Grade

Student's Phone

Student's Email

Church

Allergies

Other Medical Information

Doctor

Doctor's Phone

Insurance Carrier

Insurance ID#

Parent/Guardian Information

Primary Contact

Address

Home Phone

Cell Phone

This address will receive a confirmation email

I will receive a text message

Yes No

Home Church

Secondary Contact

Address

Phone

Parent/Guardian Approval

Approval

By checking this box, I am indicating that the above information is accurate and I agree to the terms and conditions stated in the description of this form. By entering my name in the box below, I am providing my digital signature on this form.

Electronic Signature

Date

Description

This form serves as a medical release for all IBC sponsored activities from September 1, 2026 - August 31, 2027. In the event your child needs emergency medical care, every effort will be made to contact you immediately.

I will be made aware of all activities through social media (Facebook pages IBC1Journey or Immanuel Baptist Church Wausau), our website (www.ibcwausau.org), church bulletin and/or my teens.

Should this information change, it is my responsibility to fill out a new form and turn it in to the church office.

When it is deemed necessary for my son/daughter's health, the leaders may have my son/daughter hospitalized or use outside medical, surgical, or dental aid, in which case I shall pay for all such expenses. I shall in no way hold Immanuel Baptist Church or its representatives responsible for any financial obligation.

I GIVE MY CONSENT FOR MY SON/DAUGHTER TO PARTICIPATE WITH IMMANUEL BAPTIST CHURCH, AND RECEIVE EMERGENCY MEDICAL CARE IN MY ABSENCE.

Teen Yearly Permission Form

Description

Please Fix the Following