We will be staying at the Comfort Inn.

Address: Comfort Inn.

1610 Flossie Dr.

Lawrenceburg, IN 47025

Phone: (812) 539-3600

We will be skiing at Perfect North Slopes

Address: Perfect North Slopes

19074 Perfect Pl Ln,

Lawrenceburg, IN 47025

Phone: (812) 537-3754

When and what time?

* On February 22 we will be leaving the church around 7:00-7:15. We will

stop along the way to eat dinner.

* From there we will make our way to the comfort inn in Lawrenceburg IN

probably arriving around 12AM.

* That morning we will wake up at 9AM, pack, eat breakfast and leave

around 10AM to head over to the Ski Resort.

* The passes are good for 8 hours so we will be done around 7 or 8 pm.

Lunch will be eaten at the Ski Resort.

* After the ski resort will go out to eat before heading home.

* We will hopefully arrive at the church before 1AM.

Our goal is to see decisions for Christ this week.

For any questions call Josh Stoneman at (606) 219-6564

or email at jstoneman@fbcsomerset.org

Medical Release Form This form to be completed in black or blue ink by the

minor’s parent/legal guardian

For: FBC Student Ministries

Of: First Baptist Church – Somerset, KY

Effective Date: 2013 – All Events .

Youth’s Name: ________________________________________ Birthday ____/____/____ Sex ______

Complete Home Address: ________________________________________________________________

Home Phone (_______)_______________________ Emergency Number (_______)_________________

Youth lives with: [ ] Mother [ ] Father [ ] Both [ ] Guardian

Father’s Name: ______________________________ Work Phone Number (_______)________________

Employed by: __________________________________________________________________________

Mother’s Name: ______________________________ Work Phone Number (______)________________

Employed by: __________________________________________________________________________

Guardian’s Name: ____________________________ Work Phone Number (_______)________________

Employed by: __________________________________________________________________________

MEDICAL INFORMATION

Family Physician: __________________________________ Phone Number (_______)_______________

Parent’s Insurance Company: _____________________________ Policy Number ___________________

Note: Answers to all numbered questions can be listed on the back of this form.

Chronic illnesses or medical conditions (stomach upsets, rash, frequent colds, etc)?

Medications? What?

Operations or serious injuries (dates)? DISEASE (OPTIONAL) VACCINATION DATE

Any activity restrictions? (Check, if applies. Give approximate dates.)

____ Chicken Pox ________________

Health History (Check, if applies. Give approximate dates.) ____ German Measles ______________

____ Ear Infection _________________________________ ____ Mumps ______________________

____ Heart Defect/Disease ___________________________ ____ DPT ________________________

____ Convulsions/Epilepsy __________________________ ____ TD _________________________

____ Diabetes _____________________________________ ____ Tetanus ______________________

____ Bleeding/Clotting Disorders _____________________ ____ Tuberculin Test _______________

____ Hypertension/A.D.D. ___________________________ ____ Influenza b (HIB) ______________

____ Mononucleosis _______________________________ ____ Measles _____________________

CONSENT FOR EMERGENCY TREATMENT If your child should require medical attention while on an activity with the above listed church/group for injuries received or illnesses contacted

prior to coming, please send us information necessary to give him/her proper medical service during this time. In case of emergency, I hereby give

permission to the physician selected by the church/group sponsor representative to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child as named above. I also hereby give permission for child to participate in all activities, travel, service projects,

and other activities in the FBC Student Ministries program.

I, therefore, agree to assume as an explicit condition of my child’s/ward’s participation, any and all risk, including, but not limited to these enu-

merated above. I agree to hold harmless the above named sponsor, the sponsoring church or group from any liabilities, claims, demands, and causes of action whatsoever which may arise due to the participation of myself or my child.

I realize, also that in the event of illness or injury while participating in its activity, medical treatment may be required, I hereby give permission for any such treatment to be rendered, and I agree to bear the cost of such treatment. If any changes occur, I will contact the director.

________________________________________ _________ ____________________________________________ _________

Father’s/Guardian’s Signature Date Mother’s/Guardian’s Signature Date