In the event that the Participant named above becomes ill or sustains an injury while participating in any event of the Abilene Baptist Church of Martinez, Georgia (hereinafter “the Church”), I give my permission to the Church, its staff, representatives, employees, members, directors and/or volunteers (hereinafter collectively “Released Parties”) to administer and/or seek medical treatment for the Participant.
I hereby authorize the sharing of the Participant’s medical information with any Medical Provider treating him/her. I give permission for any licensed physician, emergency medical technician, paramedic, nurse, hospital or other medical Provider to provide all medical tests and treatment deemed necessary to insure the health and welfare of the Participant.
I hereby confirm that the Student/Participant is covered and will remain covered under a policy of medical insurance with the company identified on page one unless otherwise noted.
If this coverage changes, I will promptly notify the Church. I further agree this policy of insurance will be the primary source of coverage in the case of any accident or injury while participating with the Church and I take full responsibility for all costs, deductibles, bills, and/or other expenses related thereto.
Over the Counter Medicine
In the event that the Participant named above becomes ill or sustains an injury while participating in any event of the Abilene Baptist Church of Martinez, Georgia (hereinafter “the Church”), I give my permission to the Church, its staff, representatives, employees, members, directors and/or volunteers (hereinafter collectively “Released Parties”) to administer over the counter medicine such as Acetaminophen (i.e. Tylenol), Ibuprofen (i.e. Advil), Diphenhydramine (i.e. Benadryl), etc.
I will not hold the Released Parties personally or financially responsible for any accident, injury, or illness that may occur, treatment provided or results thereto. I, for myself, the Participant, and/or the Participant’s other parent/guardian, do hereby release, and agree to indemnify, defend and hold harmless the Released Parties from and against any liability, claims, losses, damages, fines, costs, injuries, and/or death which in any way arise or result from the Participant’s participation with the Church. I further agree to waive any rights of legal action against the said releases and covenant not to sue. This Consent shall be binding on me, my representatives, heirs, next of kin, beneficiaries, successors and assigns.
I hereby grant the Released Parties permission to photograph and record the Participant while participating with the Church. I further consent that all photographs and videos depicting the Participant may be used, published, printed and/or distributed for any and all purposes, including but not limited to advertising, publicity, promotions litigation and surveillance. I acknowledge that these photographs and videos may be viewed in any manner, in any and all medium, in perpetuity without restriction or alteration. I waive any right to pre-inspection or approval of the use of the photographs and videos. I acknowledge and agree that the rights granted herein are without compensation of any kind. I further acknowledge that I have no rights, title or interest in any photographs or videos as they are the exclusive property of the Released Parties.
Should it become necessary to send the Participant home for disciplinary reasons, I assume the responsibility of transporting the Participant home. I also consent to the Participant’s belongings being searched at any time while participating in an activity of the Church and the confiscation of any unauthorized items by the Released Parties.
I agree that the information and responses I have provided on this form are true and accurate.
I agree to notify Abilene Baptist Church if any information on this form changes.