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Parental Consent, Certification, and Medical Authorization

As the parent (or legal guardian), I the undersigned, certify that my child, named above, has my express permission to participate in all activities, of any nature, including transportation to and from the activity, sponsored by the 3Circle Church for the calendar year January 1, 2022 through December 31, 2022. Knowing that 3CC will always try to act responsibly, I fully release 3Circle Church, its authorized I hereby fully release 3Circle Church, Inc., its representatives, staff, directors, members, volunteers and agents from all liability of any kind and character upon any claim, demand, or cause of action which might be asserted in our behalf against said church, its representatives, staff, directors, members, volunteers and agents.

I, the undersigned parent or guardian of such minor child (or children) as listed below, and on their behalf, do hereby release, acquit and forever discharge and agree to hold harmless 3Circle Church, Inc., its representatives, staff, directors, members, volunteers and agents, from any and all actions, causes of action, claims, demands, costs, expenses and compensation in any way arising out of my child’s participation in events or activities sponsored by 3Circle Church, Inc..

It is understood and agreed that this is a full and complete release and waiver of all claims and damages, including future claims, as a result of participation in said activities by reason of injury, negligence, or other cause, and all losses as a result thereof. It is further understood and agreed that in the event that any claim is asserted against released parties, I will hold them harmless from such claim.

It is my understanding that the church will attempt to notify me in case of a medical emergency involving my child. If the church cannot reach me, then I authorized the church to hire a doctor or other health-care professional, and I give my permission to the doctor or other health-care professional to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred. I will notify the church if I feel there are any health considerations that would prevent my child’s participation in an activity. I also give my permission for church leaders to restrict my child from participation in any activity which they have any question about for health or other reasons.

Dated: December 6, 2022

State of Alabama: County of Baldwin:

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
First Participant's Signature*
Second Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Third Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Fourth Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Fifth Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Sixth Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Seventh Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Eighth Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Ninth Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Tenth Participant's Name

First Name*

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

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
Parent or Guardian's Email Address

Email*

Confirm Email*
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Insurance

Insurance Carrier*

Insurance Policy Number*
Additional Information

Father


Name

Home Phone

Work Phone

Cell Phone

Mother


Name

Home Phone

Work Phone

Cell Phone
LOCAL relative or friend to notify in case of an emergency (if we cannot locate parent):

Name *

Telephone *
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Doctor's Name

Chart #

Telephone

Known Allergies

List any medications or drugs taken regularly
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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