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I understand that my signature conveys the following:

  1. I hereby grant the above-named participant (if minor) my permission to participate in various church sponsored youth trips, outings and camps.
  2. I further give my permission for church representatives to secure necessary medical treatment for above-named participant if I cannot be reached.
  3. I knowingly release, absolve, indemnify, and hold harmless Summer Creek Baptist Church of Houston, Texas, its employees and representatives from all claims that might result from any injury or death of above-named participant.
  4. Should medical treatment be required, I agree to pay all medical/hospital costs, either directly or through my personal insurance policy.
  5. I further understand and agree that in the event the above-named participant be involved in activities that violate or compromise the rules, polices, or purposes of Summer Creek Baptist Church, I accept full responsibility including related expenses for release of participant.
  6. By signing this document, I confirm that I have the authority to sign, have read the entire document, and understand that the document waves certain rights of the person signing and the participant.

​Today's date: May 31, 2025

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Third Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Fourth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Fifth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Sixth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Seventh Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Eighth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Ninth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Tenth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Insurance
Insurance Carrier*
Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Doctor:
Office Phone:

Known food/drug allergies:

Medication taken regularly:
Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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