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PROGRAM WAIVER 2021-22

“FILL OUT ONE FORM PER FAMILY PER YEAR”

Your privacy is important to us; this information is collected simply to help us keep our database up to date. This information will not be shared outside of Springvale.

WAIVER & RELEASE FORM

I/we, the parents or guardians named on this registration, authorize a Springvale Baptist Church Representative or one of the Springvale Baptist Church Ministry Staff to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant(s) named in this registration.

I/we, named on this registration, undertake and agree to indemnify and hold blameless the Ministry Staff, Springvale Baptist Church, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant(s) as a result of being part of the activities of Springvale Baptist Church, as well as of any medical treatment authorized by the supervising individuals representing the church.

I/we, named on this registration give Springvale permission to use photographs or videos of any member of my family to use and publish the photographs or videos in print or electronically for any lawful purpose to highlight and promote Springvale Kids/Youth ministries. This undertaking includes the right to modify and retouch the images in the discretion of Springvale Church. This also includes the tagging of youth in social media. I also understand that my child in Springvale Youth may be contacted for ministry purposes via social media.

This consent and authorization is effective only when participating in or travelling to the events of Springvale Baptist Church. I hereby give permission and consent for my child(ren) to be transported for kids/youth activities on behalf of Springvale Baptist Church by the individuals deemed eligible by Springvale Baptist Church.

I have read, understood and agree with the above and sign it to cover all Springvale Kids and Springvale Youth activities for the program year effective September 2021 to August 2022.

Today's Date: May 28, 2022

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
First Participant's Signature*
Second Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Third Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Fourth Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Fifth Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Sixth Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Seventh Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Eighth Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Ninth Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
Tenth Participant's Name

First Name*

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

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
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*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional Details

How did you hear about Springvale Kids or Springvale Youth?

Parent / Guardian #2 Name

Phone
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Grade (Sept 2021)

Allergies, Medical Concerns or any Exceptional Needs?
Child(ren) resides with:*

Please let us know of any custody concerns.
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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