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I understand that my signature conveys the following:

  1. I hereby grant the above-named participant (if minor) my permission to participate in various church sponsored youth trips, outings and camps.
  2. I further give my permission for church representatives to secure necessary medical treatment for above-named participant if I cannot be reached.
  3. I knowingly release, absolve, indemnify, and hold harmless Summer Creek Baptist Church of Houston, Texas, its employees and representatives from all claims that might result from any injury or death of above-named participant.
  4. Should medical treatment be required, I agree to pay all medical/hospital costs, either directly or through my personal insurance policy.
  5. I further understand and agree that in the event the above-named participant be involved in activities that violate or compromise the rules, polices, or purposes of Summer Creek Baptist Church, I accept full responsibility including related expenses for release of participant.
  6. By signing this document, I confirm that I have the authority to sign, have read the entire document, and understand that the document waves certain rights of the person signing and the participant.

‚ÄčToday's date: August 19, 2022

First Participant's Name

First Name*

Middle Name

Last Name*

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Third Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Fourth Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Fifth Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Sixth Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Seventh Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Eighth Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Ninth Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
Tenth Participant's Name

First Name*

Middle Name

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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
No
Yes
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*
Insurance

Insurance Carrier*

Insurance Policy Number*
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

Doctor:

Office Phone:

Known food/drug allergies:

Medication taken regularly:

Date of last tetanus shot/booster:
Photo Release: I grant Summer Creek Baptist Church the right to photograph/film above named participant during any church sponsored activities, with the understanding that pictures/videos may be used in promotional materials or otherwise published in print, digital or web form*
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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