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I understand that my signature conveys the following:
I hereby grant the above-named participant (if minor) my permission to participate in various church sponsored youth trips, outings and camps.
I further give my permission for church representatives to secure necessary medical treatment for above-named participant if I cannot be reached.
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.
Should medical treatment be required, I agree to pay all medical/hospital costs, either directly or through my personal insurance policy.
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.
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.
Today's date: December 11, 2024
Please select who will be participating...
Adult
Minor(s)
1 Minor
2 Minors
3 Minors
4 Minors
5 Minors
More Minors
6 Minors
7 Minors
8 Minors
9 Minors
10 Minors
Continue
First
Participant's
Name
First Name
*
Last Name
*
Phone
*
First
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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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
*
Type Signature
Draw Signature
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Clear
Close
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Clear
Close
Click to Sign
Edit Signature
Second
Participant's
Name
First Name
*
Last Name
*
Phone
*
Second
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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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
*
Last Name
*
Phone
*
Third
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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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
*
Last Name
*
Phone
*
Fourth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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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
*
Last Name
*
Phone
*
Fifth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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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
*
Last Name
*
Phone
*
Sixth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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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
*
Last Name
*
Phone
*
Seventh
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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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
*
Last Name
*
Phone
*
Eighth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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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
*
Last Name
*
Phone
*
Ninth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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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
*
Last Name
*
Phone
*
Tenth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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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:
*
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Cote D'ivoire
Croatia
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia, The
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and the McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
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Samoa
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Serbia
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Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Taiwan
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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
*
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
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
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
*
Type Signature
Draw Signature
Change Font
Accept Signature
Clear
Close
Accept Signature
Clear
Close
Click to Sign
Edit 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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Agree To This Document