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First Baptist Church

Plainview, Texas 79072

Consent, Waiver and Release Agreement

State of Texas County of Hale Know all men by these present; that The undersigned, (or parent or guardian) (below) Whose address is (below) for and in consideration of being allowed to participate in the programs and activities of First Baptist Church, Inc., Plainview, Texas being sometimes herein referred to as the “Church” including, but not limited to, programs of the Activities Ministry of the Church, and excursions or field trips sponsored by the Church or any of its related suits and/or actions which may hereafter be instituted by the undersigned for damages resulting from illness or injuries of whatsoever nature sustained by the undersigned or participant while participating in the activities of the Church or any related undertaking, this Agreement shall be urged and taken advantage of by the Church as a bar to any such recovery by the undersigned on account of any injury of illness or injury sustained.

For the same consideration above recited, the undersigned does hereby release and discharge First Baptist Church, Inc., its representatives, agents, servants and/or employees of account of any injuries or illness sustained to or by the undersigned by whatever cause or reason; and the undersigned does hereby agree to hold harmless and indemnify the said First Baptist Church Inc., its agents, servants, representatives, and/or employees against any loss, damages or costs of whatsoever nature which it or its agents, servants, representatives or employees may suffer as a result of any action, claim or demand by the undersigned or by any other person on behalf of or for the benefit of the undersigned.

This Agreement shall insure to the benefit of and be binding upon the respective heirs, successors and assigns of the parties hereto.

The Church does not carry any insurance to cover the illness or injury of any person, and by the execution hereto, the undersigned acknowledges such fact.

Executed this day: May 21, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant'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 or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parents' Information if Under 18 Years of Age:

Name of Parents:

Address of Parents

Home phone #

Mother's Employer:

Employer Address:

Phone #

Father's Employer:

Employer Address:

Phone #:
Insurance Information:

Name of Medical Insurance Company:

Policy #
Medicare?*
No
Yes

Policy #

Doctor Preference:

Doctor's address

Phone #

Hospital Preference

List any Allergies:

List Medications Individual Takes:
Medical Consent

In the event of accident or illness concerning the above named, First Baptist Church, Inc., will use its best effort to contact the person named immediately. In the event that person is not immediately available, the Church is authorized to secure such medical attention and care for the child as under the circumstances to the Church may seem proper, and if reasonably possible, the above named preferences shall be adhered to. The parents or guardian of minors shall assume full responsibility for all medical bills, doctor bills, and hospital bills, it being understood and agreed that pursuant to the Consent, Waiver and Release Agreement on the reverse side hereof, First Baptist Church, Inc., its agents, servants, and employees shall not be responsible or liable for any injuries, sickness or other medical problems of the above named child. The Church does not carry any insurance to cover the illness or injury of any child, it being the parent's responsibility to furnish such insurance as the parent may desire.

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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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