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2019

AUTHORIZATION, CONSENT AND RELEASE FOR A MINOR

Transportation I authorize Athey Creek Christian Fellowship (ACCF), its agents and employees to provide transportation for the child for ACCF outings. It is not necessary that I be contacted for permission each time the church provides transportation for a trip.

Medical Treatment In the event that an illness or injury befalls the child, either on or off the Fellowships premises, ACCF should first attempt to contact the parent and then the guardian, friend, or relative listed below to make arrangements for the childs care. If none of those persons can be quickly located, or in the case of an emergency, I authorize ACCF to:

1. Contact the physician listed below and follow that physicians instructions

2. Transport the child to a medical facility and make decisions on my behalf as to the treatment

3. Consent to treatment by the physician named below or, if that physician is not available, then ACCF is authorized to obtain and give consent for any recommended examination, care, and treatment of the child named below.

Photography - I hereby grant ACCF permission to use the childs image, likeness, and the sound of his or her voice as recorded by audio or video recordings, or in a photograph in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of ACCF, are copyright protected by ACCF, and will not be returned. I hereby irrevocably authorize ACCF to edit, alter, copy, exhibit, publish or distribute this photo (or photos) for purposes of publicizing ACCFs programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein the childs likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph(s).

Release I, individually and as guardian of the child named below, hereby hold harmless, waive, release, and forever discharge ACCF (its employees, agents and representatives) from any and all claims, demands, liability, causes of action, and damages which I, the child, my heirs, representatives, executors, administrators, or any other persons have or may have, resulting directly or indirectly from the childs participation in ACCF activities, including transportation as to those activities, and/or by reason of ACCFs use of the photography and/or audio/video as described herein. There is no time limit on the validity of this release nor is there any geographic limitation.

First Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
First Child's Signature*
Second Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Third Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Fourth Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Fifth Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Sixth Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Seventh Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Eighth Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Ninth Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Tenth Child's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Child's 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/Guardian's Email Address

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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent/Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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/Guardian's Name

First Name*

Middle Name

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

Medical


Date of Last Tetanus Shot:

Medications:

Allergies:
Parent/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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