2008 First Baptist Nashville Release Form

I authorize the Designated Agents (as hereinafter defined) of First Baptist Church, 108 Seventh Avenue South, Nashville, Tennessee 37203 (the "Church"), to consent to, and to execute any and all documents necessary for my child, (the "Child"), to be treated by a medical doctor or a medical facility, whether on an emergency or non-emergency basis, if such care be determined necessary for his or her care, health and general welfare during any activity or event associated with the Church.

Designated Agents

For purposes of this Medical Authorization and Release, the "Designated Agents" are defined to be the following: Josh Crosby, Frank Lewis, Sam Sanders, Rus Roach, Tom Crow, Lacy Tite, Laurie Hall, Bonnie Holmes, those persons identified as adult counselors and sponsors for an activity or event associated with the Church in an affidavit executed by any of the individuals listed above and presented with this Medical Authorization and Release at the time medical treatment is requested for the above-named Child.

This authorization shall remain in effect, from this date until December 31, 2008, unless sooner revoked in writing by me. I hereby release the Designated Agents from any claims, liabilities, demands, damages, rights and causes of action resulting or arising, directly or indirectly, from any consent or action taken by him or her pursuant to this Medical Authorization and Release.

I give permission for First Baptist Church to use photos taken of my child at church events in promotional items, on the website and in print publications (i.e. The Evangel, midweekly, etc). Yes No

Insurance Information

If possible, a copy of the insurance card is attached.

My medical insurance carrier is:

Policy/Group No

Policy is carried by:

I am either in active military service or am retired. My child is entitled to military medical care and my identification number is:

I do not have medical insurance, but I authorize any necessary medical care to be charged to the following credit card account:

Account Number Expiration Date Credit Card Signature

Emergency Contact Information

If necessary, I can be reached at the following phone numbers:

Home	Work	Cell
Beeper	Other
My child's primary physician is: Physician Phone

Special Health Considerations

Date or Year of last Tetanus Shot: Blood Type

Does your child have any allergies? No Yes
If yes, use this box to describe

Does your child take any medication regularly? No Yes:
If yes, use this box to describe

Does your child have any physical limitations? (asthma, diabetes, recent injuries, etc.) No Yes
If yes, use this box to describe

Special instruction in addition to above which might be helpful to physician:
Use this box to describe

Parent or Guardian Signature
(Must be Acknowledged by Notary Public)

Date

STATE OF _________________ COUNTY OF _______________ SUBSCRIBED AND SWORN TO before me,
by the said ____________________ on this the ______ day of ___________, 2008.

[NOTARY SEAL HERE]

_____________________________________________
NOTARY PUBLIC STATE OF TENNESSE

Name: ________________________________________
My Commission Expires: _________________________