RELEASE FORM | Memorial Baptist Church

Name of Attendee *

First

Last

Birthdate *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Attendee Email (if applicable) *

Attendee Phone (If applicable)

Child Grade

Father's Name *

First

Last

Mother's Name *

First

Last

Father's Email *

Mother's Email *

Father's Mobile Phone

Mother's Mobile Phone

Does the attendee and parent(s) live at the same address? If No, please provide the address for the primary emergency contact below *

Yes
No

Primary Emergency Contact *

First

Last

Emergency Contact Number *

Generally, the attendee's health is: *

Excellent
Good
Fair
Poor

If you marked Fair or Poor above, please explain:

List any pre-existing or present medical conditions:

List name and dosage of any current medications:

List any medications or food for which you are allergic:

Do you suffer from any of the following conditions? Check all that apply. *

If you checked any of the above options, please give details below: (for example, include normal treatment of allergic reactions)

Date of last tetanus shot: *

Do you use contact lenses?

Yes
No

Are there any activity restrictions we should know about? *

Yes
No

If you check yes, please give details below:

Name of Family Physician: *

Physician Phone: *

Insurance Company: *

Policy or Group #: *

Name of Subscriber *

First

Last

Phone Number of Subscriber *

Subscriber Place of Employment: *

Subscriber Occupation:

Work Phone *

I, the undersigned, do hereby verify that the above information is correct and accept all responsibility to notify and submit an updated release to Memorial Baptist Church if any of the information changes. I, the undersigned, accept financial responsibility for the well being of the above named person and hereby authorize Memorial Baptist Church, their employees, associates, or volunteers in charge to obtain medical attention in the case of sickness or injury. I also authorize the attending physician or dentist to provide any and all required medical treatment. I, the undersigned, do release and forever discharge all sponsors, Memorial Baptist Church, their employees, associates, and volunteers from any claim, demands, actions or cause of action, past, present, or future arising out of any damage, injury, loss of property or death while participating in Memorial Baptist Church ministries. I, the undersigned, grant permission for the above to participate in all the recreational activities for the year with Memorial Baptist Church. I understand some recreational activities involve a certain degree of risk that could result in injury or death. I have carefully considered the risk involved and agree to release Memorial Baptist Church, their employees, associates, and volunteers from any and all liability which could result from participating in these recreational activities. I, the undersigned, grant permission and release Memorial Baptist Church, their employees, associates, and volunteers from any and all liability when transporting the named person above to and from these events. I, the undersigned, understand that as a participant my child may be photographed or video taped during normal Memorial Baptist Church ministry activities and I hereby grant permission for those photos/videos to be used by Memorial Baptist Church. I, the undersigned, accept that a copy of this form is as valid as the original. *

I consent

I understand as a parent that it is my duty to make myself aware of any event that my child is taking part in. I will use foresight when deciding what events my child is able to take part in. I understand that dropping my child off, or someone else dropping them off at an event means that he/she has my permission to take part in that event. I understand I have multiple ways (phone call, text, email, or in person) to ask absolutely any question about anything my child will be taking part in. I also understand that it is impossible for leaders of Memorial Baptist Church, their employees, associates, or volunteers to keep an eye on my child at all times and it is my responsibility to make sure my child understands that they are to conduct themselves in a responsible manner and obey the rules they are given. I understand that when my child attends any event that they are obligated to stay with the group and not allowed to do whatever they want but must comply with what the group is doing. I will also not hold Memorial Baptist Church, their employees, associates, or volunteers responsible if my child makes an unforeseen bad decision that may result in death or injury. I will not hold Memorial Baptist Church, their employees, associates, or volunteers responsible for any injury that occurs to my child when safety equipment is provided or suggested and rejected by my student (i.e. Seatbelt or lifejacket). Finally, I am giving my child permission to swim in waters that are not protected by lifeguards. I understand that I am responsible for sending any and all safety equipment that my child needs for swimming and it is my parental responsibility to make sure my child uses and knows how to operate such device. *

I consent

As parent/legal guardian of the child named above, I will review information about any youth ministry activity/event that my child attends and I give my permission for him/her to be involved in the activity. I also authorize this permission form to be valid for one full year from the date signed. *

I consent

As parent/legal guardian of the student named above, my child is aware of the stipulations above and agrees to abide by them. If my child fails to do so, I understand and agree that at my own expense I will travel to and pick up my child from any event in a timely manner at the request of Memorial Baptist Church, their employees, associates, or volunteers. *

I consent

Signature

Clear Signature

Date *