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This form is to be submitted yearly for all youth and children as well as adult leaders/volunteers attending Ardmore Baptist Church effective August 1, 2019 through August 31, 2020.

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

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

FOOD/DRUG ALLERGIES and MEDICAL CONDITIONS *

LIST ALL MEDICATIONS (prescriptions, EpiPen, insulin, etc.) *
TYPE OF PARTICIPANT*
Child (birth - 6th grade)
Youth (7th - 12th grade)
Adult Volunteer
Participant grade level*

School participant attends.
T-Shirt size for participant*
I grant permission for my child's photo to be used in worship, the newsletter, website and/or social media.*
YES
No
I grant permission for my child's name to be tagged in social media and website photos.*
No
Yes
For children: select N/A. For youth: I grant permission for my child to be contacted in the following ways: *
Text to child's cell phone
Call child's cell phone
Email
Social media
N/A

Student cell phone number (for youth in 7th - 12th grades)
First Participant's Signature*
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Insurance Company Contact Information

Insurance Company Phone Number *
Second Parent/Guardian Contact Information (if applicable)

Second Parent's/Guardian's Name

Second Parent's/Guardian's Email

Second Parent's/Guardian's Phone Number
Backup Emergency Contact Person

Second Emergency Contact Name *

Second Emergency Contact Phone Number *
Primary Physician Information

Primary Physician's Name *

Primary Physician's Phone Number *

Primary Physician's Address *
This is a liability release, medical authorization, basic information, contact information, and photo/social media permissions form.

LIABILITY RELEASE (Release of All Claims) In consideration for being accepted as a participant in Ardmore Baptist Church activities, we (I), being 21 years of age or older, do hereby release, forever discharge and agree to hold harmless Ardmore Baptist Church, Inc. and its agents, employees, directors, and anyone acting on its behalf from any and all liability, claims or demands for personal injury, sickness or death, including claims for emotional distress, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in activities sponsored by or in any way related to Ardmore Baptist Church, Inc. This includes, but is not limited to, any activity on the property of Ardmore Baptist Church, Inc. and all off site activities connected with Ardmore Baptist Church, Inc. Furthermore, we (I) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in any activity recreation and work activities involved therein. We (I) understand that there are risks of injury associated with the activities my child-participant is going to be engaged in, and we (I), with knowledge of those risks, agree that no claim, suit or demand of any kind will be made against Ardmore Baptist Church, Inc. This includes, but is not limited to, those claims, suits, or demands arising out of the negligence of Ardmore Baptist Church, Inc. and its agents, employees, directors, and anyone acting on its behalf. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs. Further authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including all expenses and attorney fees incurred attendant thereto. MEDICAL AUTHORIZATION We (I) hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. The undersigned hereby give permission for my (our) child, named above, to attend and participate in activities sponsored by Ardmore Baptist Church, Inc from August 1, 2019 to July 30, 2020. I (we) also give permission for my (our) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Ardmore Baptist Church.
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*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Other Important Information

FOOD/DRUG ALLERGIES and MEDICAL CONDITIONS *

LIST ALL MEDICATIONS (prescriptions, EpiPen, insulin, etc.) *
TYPE OF PARTICIPANT*
Child (birth - 6th grade)
Youth (7th - 12th grade)
Adult Volunteer
Participant grade level*

School participant attends.
T-Shirt size for participant*
I grant permission for my child's photo to be used in worship, the newsletter, website and/or social media.*
YES
No
I grant permission for my child's name to be tagged in social media and website photos.*
No
Yes
For children: select N/A. For youth: I grant permission for my child to be contacted in the following ways: *
Text to child's cell phone
Call child's cell phone
Email
Social media
N/A

Student cell phone number (for youth in 7th - 12th grades)
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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