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Medical Liability Release Form, General Permission & Code of Conduct

General Permission
I give the participant listed on this form permission to go with Mount Vernon Baptist Church on their various student ministry events and outings. These events and outings range from concerts, camps, retreats, local non-recreational activities and mission projects. I realize that this is a general form to be placed on file in the student ministry office upon which the church may use when necessary. I also understand that for some student ministry events there will be an additional form to be used to notify of parental consent for various events.

Personal Property Waiver
I understand that it is my responsibility to safeguard any personal property I bring. I further understand that Mount Vernon Baptist Church will not under any circumstances be responsible for any property lost, misplaced, or stolen, either directly or indirectly. I further understand that such loss may or may not be covered under my insurance and that Mount Vernon does not have any insurance to cover any such loss of my own personal property.

Photo/Video Notice
I understand that as a participant, my child may be photographed or videotaped during normal activities and that these photographs or videos may be used in other materials.

Liability Release
As the parent/guardian of the participant, I certify that the information provided on this form is correct to the best of my knowledge. In order that appropriate diagnosis and treatment may be promptly carried out and so that no unnecessary delays will occur, I give permission for such diagnostic, therapeutic, and operative procedures as may be deemed necessary for the person named. No major operation will be performed, however, except in an emergency, without a parent or guardian being contacted and fully informed. I assume final responsibility for medical expenses incurred by the participant, and for expenses involved in returning the participant home for medical reasons, or for any of the following reasons substance abuse (drugs and alcohol), endangering the life of another person, sexual misconduct, or illegal misconduct. I understand that each individual is responsible for his/her own insurance coverage during any trip. I hereby release and forever discharge Mount Vernon Baptist Church, its staff, all sponsors, state conventions, employees, and any designated individual in charge of any trip from any legal responsibility, financial responsibility, all claims, demands, actions or cause of ac- tion, past, present, or future with respect to my personal or child’s participation in any church activity.

Code of Conduct Agreement
Parent/Guardian Agreement

After reading the Code of Conduct I give the Student Ministry staff of Mount Vernon Baptist Church permission to enforce the Code of Conduct in agreement with the student ministry philosophy. I give the Student Ministry leadership permission to use their discretion, knowing that a team approach will be utilized to enforce rules and make final decisions as to the severity of the reprimand. If my child is seen by the Student Ministry leadership as having an infraction of these rules and regulations, I will support their decision of the reprimand and follow through with the understanding in Section 2 of the Code of Conduct document.

Student Agreement
After reading the Code of Conduct I understand the seriousness of the Code of Conduct and will respect it and the adult leadership at all times. I will strive to obey these important regulations as they will provide for me a safe, good and healthy experience. If infractions of any of these guidelines are made, I will take responsibility and follow the above agreement in Section 2 of the Code of Conduct document.

Participation Agreement
I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The par- ticipant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

Date submitted: October 1, 2022

 

Mount Vernon Baptist Church • 11220 Nuckols Road • Glen Allen, VA 23059 • (804) 270-6600 • mvbcnow.org

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AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Please describe any medical condition which may recur or be a factor in medical treatment.


Illness or handicaps

Allergies to medication,

Allergies to food/environment

Convulsions, Blackouts, Fainting Spells, Etc.

Heart or lung problems

Disease of any kind

Previous operations or serious illnesses

Other (medical conditions)

Regular Medications Currently Taking

Dosage and Frequency

Short Term Medications Currently Taking

Dosage and Frequency

Over the counter medications allowed to take
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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*

Family Physician *

Phone *

Medical Insurance Company *

Subscriber Name *

Type of Coverage *

Group # *

Policy # *

Insurance Phone *

Parent/Guardian Work Phone

Parent/Guardian Address (if different)
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*

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

Please describe any medical condition which may recur or be a factor in medical treatment.


Illness or handicaps

Allergies to medication,

Allergies to food/environment

Convulsions, Blackouts, Fainting Spells, Etc.

Heart or lung problems

Disease of any kind

Previous operations or serious illnesses

Other (medical conditions)

Regular Medications Currently Taking

Dosage and Frequency

Short Term Medications Currently Taking

Dosage and Frequency

Over the counter medications allowed to take
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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