PBC Youth Permission and Health Form 2025

Your name *

Last name

Email address *

Child's Name *

Birthdate

Address

HomeWorkOther

Country

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Grade

Select…Pre-KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade

Emergency Contact *

Phone number

Phone type

MobileHomeWorkOther

Insurance Company *

Group ID #:

Policy #:

Does our child have any known allergies? *

Select…YesNo

List any and all medical conditions your child may have: (if none, leave blank)

Does your child take any medications? *

Select…YesNo

My child may be photographed while on activities and camp for social media pages and slideshows

Select…YesNo

Household members

+ Add adult+ Add child

I acknowledge that the above information is correct and that Piedmont Baptist Church is NOT responsible for any lost or damaged items that may accour at a camp, activity or etc, ... *

Submit

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.