Participant Permission - Medical Release
  1. THIS FORM IS FOR ALL 2017-18 STUDENT MINISTRY ACTIVITIES, EVENTS, RETREATS AND TRIPS
  2. Participant's Name(*)
    Please provide the student's name.
  3. Date of Birth(*)
    / / DOB required.
  4. Age(*)
    Age required
  5. Grade(*)
    Please choose your student's grade level
  6. Parent / Guardian Name(*)
    Please provide your name.
  7. Parent / Guardian Email(*)
    Email Required
  8. Parent / Guardian Phone(*)
    A phone number is required.
  9. Alternate Phone
  10. Address(*)
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  11. City(*)
    Invalid Input
  12. State(*)
    Invalid Input
  13. Zip(*)
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  14. Permission

    • I do hereby verify the information given on this form is correct.
    • I do hereby give permission for my above-named child to participate in and to be transported to and from ALL activities, events, retreats or trips sponsored by the Student Ministry of Liberty Baptist Church, Dalton, GA during 2017-2018.
    • I understand that this permission/release will apply to all planned activities, events, retreats or trips sponsored by the Student Ministry of Liberty Baptist Church during the 2017-18 year,
    • I understand that, in the case of an emergency Liberty Baptist Church, employees, agents and/or sponsors will make every effort to contact me and/or the contact person named below, however;
    • Should the named contact person, or myself, be unavailable to make decisions regarding my child’s care, I do hereby grant permission for Liberty Baptist Church employees, agents and/or sponsors to obtain emergency medical attention in case of sickness or injury, to my child.
    • Should the named person or myself, be unavailable to make decisions regarding my child’s care, I do hereby grant permission for an attending physician or hospital to perform whatever care is deemed necessary by Liberty Baptist Church employees, agents and/or sponsors for the welfare of my child.
  15. Hold Harmless

    In consideration for you allowing my child to go on said activities, events, retreats or trips:
    • I hereby release, absolve, indemnify, hold harmless, and forever discharge Liberty Baptist Church, its employees, agents, organizers, sponsors, or any supervisors appointed by them from any and all claims, demands, actions or cause of actions, past, present, or future arising out of injury or damage to my child while participating in any activity, event, retreat or trip.
    • I assume all risks and hazards incidental to the conduct of the activities, events, retreats or trips and transportation to and from these activities, events, retreats or trips. In case of injury to my child, I hereby waive all claims against Liberty Baptist Church, its employees, agents, organizers, sponsors, or any supervisors appointed by them. I likewise release from responsibility any person transporting my child to and from said activities, events, retreats or trips.
    • I agree that any dispute, claim, questions, or disagreement arising out of or relating to said activities, events, retreats or trips, which can not be otherwise resolved shall be submitted to mediation and if necessary legally binding arbitration as adopted by the Administrative Office and legal counsel. As a result, I expressly waive any and all rights at law and equity to bring any civil matter before a court of law; except that judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof.
    • I agree to provide medical insurance for my child.
  16. Photography Consent:

    I understand that Liberty Baptist Church regularly photographs, videotapes, or records by other visual or sound recording devices during our worship services, Sunday school and other church sponsored activities, events, retreats and trips. In consideration for allowing my child to participate in said activities, events, retreats and trips, I consent to my child’s photograph, likeness or image being used by Liberty Baptist Church in video presentations, publications, promotions, on their web site or in any other lawful manner.
  17. Medical Insurance Information

  18. Family Insurance Company(*)
    Required
  19. Policy #(*)
    Required
  20. Family Physician(*)
    Required
  21. Phone(*)
    Required
  22. Check applicable box(es) and give appropriate information below:(*)
    Required
  23. Additional Information
    Invalid Input
  24. Other medical conditions or medications that we need to be aware of
    Invalid Input
  25. Immunization - Tetanus: Date Received(*)
    Required
  26. Emergency Notification

    If I am unavailable in the case of emergency please notify:
  27. Name(*)
    Required
  28. Phone(*)
    Required
  29. Alternate Phone(*)
    Required
  30. If you choose to later revoke this permission/release, it must be done in writing.
  31. Your Signature(*)
    Signature Required