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Consent & Medical Release Form


Medical Consent

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 Agree

Medical Insurance

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.

I Agree

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 Agree

Liability Release

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 Agree

Photo Release

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.

I Agree

Discipline

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

Verification

I agree that the information and responses I have provided on this form are true and accurate. 

I Agree

Notification

I agree to notify Abilene Baptist Church if any information on this form changes. 

I Agree


First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Physician Information

Physician's Name *

Physician's Phone Number *
Insurance

Insurance Carrier*

Insurance Policy Number*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Participant's Phone Number
Participant's Grade*

Allergies - Please list here.

Dietary Restrictions - Please list here.

Medications - Please list here.

Medical Conditions - Please list here.

List anything else we may need to know.
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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