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Fill out your Medical Consent / Limited Release Form to participate in all areas of HBC Community Life!

In the event that my child becomes ill is injured while on an authorized and chaperoned activity sponsored by Highland Baptist Church (whether on or off the church property), I  give my permission and consent to the adult sponsors to administer first aid and/or CPR and to select a physician and/or hospital for my child’s care, releasing only HBC and the adult sponsors from liability for their actions.

This Limited Release does not in any way release any medical provider or entity other than HBC and its adult sponsors.

            I hereby give  the physician and/or hospital and/or emergency care personnel, as selected by the adult sponsors, permission to hospitalize, treat, and administer drugs or medicine, radiology, anesthesia, medical (or dental) or surgical diagnosis, and treatment to my child upon the advice of a duly licensed physician, surgeon, or other qualified medical personnel.

            Further, I give EMS or any other emergency transportation service  permission to transport my child.

            I understand that Consent and Limited Release will apply to all emergency situations present and future, and that a copy of this form is as valid as the original.  This Consent and Limited Release form shall remain in effect until written revocation is given to HBC.

I Agree
April 25, 2024

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

First Name*

Middle Name

Last Name*

Phone*
First Participant Date of Birth*
First Participant Information

Allergies (food, medication, etc.)

Medications (list each, amount, schedule for taking, etc.)

Other Pertinent Information
T Shirt Size*
Adult S
Adult M
Adult L
Adult XL
Children's S
Children's M
Children's L
I agree that Highland Baptist Church may photograph and record my child / dependent's likeness and activities during church related activities. I grant Highland Baptist Church all rights to use these sound, still, or moving images in any medium, digital or print, for educational, promotional, advertising, or other purposes that support the mission of the church. I understand that this release will remain in effect until the time is revoked in writing by me, or until the child is no longer a minor.*
No
Yes
First Participant Signature*
Participant 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

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Important Info

Doctor or Primary Care Provider (Name, Address, Phone Number)

Additional Emergency Contact (Name, Phone, Relation)

Secondary Address if Applicable
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Allergies (food, medication, etc.)

Medications (list each, amount, schedule for taking, etc.)

Other Pertinent Information
T Shirt Size*
Adult S
Adult M
Adult L
Adult XL
Children's S
Children's M
Children's L
I agree that Highland Baptist Church may photograph and record my child / dependent's likeness and activities during church related activities. I grant Highland Baptist Church all rights to use these sound, still, or moving images in any medium, digital or print, for educational, promotional, advertising, or other purposes that support the mission of the church. I understand that this release will remain in effect until the time is revoked in writing by me, or until the child is no longer a minor.*
No
Yes
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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