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PLEASE RETURN! THIS FORM IS GOOD FOR ALL January 01, 2022 to December 31, 2022 TRIPS!

All participants in any outing or event with First Baptist Church of Sylacauga (FBCS) must have a current signed waiver/release form on file. This includes all participants under 19 years of age, adults, and children of adult leaders.

Church: First Baptist Church, 10 S. Broadway, Sylacauga, AL 35150; 256-245-6301, www.joinfirst.net 

Consideration: I acknowledge the personal benefits accruing to my child (and me) by reason of participation in the above described outing/event and am aware of the activities my child (or I) will be participating in.

WAIVER AND INDEMNITY AGREEMENT

CHURCH SPONSORED OR HOSTED EVENTS

PERMISSION CLAUSE: By my signature below, I agree if I or my child (hereafter referred to as the participant), becomes ill or sustains injury while on an outing with FBCS or while attending an event hosted by FBCS, a staff member or representative of FBCS has my permission to administer first aid and/or take the participant to the nearest medical facility for additional treatment. I also agree to hold harmless FBCS, any of FBCS's ministers, staff, chaperones, and/or volunteers personally or financially responsible for any accident or illness which may occur during an event or outing.

PHOTO RELEASE AGREEMENT: I further understand photographs or video recordings may be created during these events (including Sunday and Wednesday activities), and I give permission for FBCS to use any or all recordings of the participant in publications, videos, website design, or other media expressions (including social media). I waive all rights to control any aspect of these photographs and recordings.

DISCIPLINARY AGREEMENT: In the event it become necessary to send my child home for disciplinary reasons, by my signature below, I agree to assume responsibility for any cost incurred.

Medical Consent/Media Release Form

MEDICAL INSURANCE AGREEMENT: I hereby confirm the participant is covered and will remain covered under a medical insurance policy. If this coverage changes, I will promptly notify FBCS at 256.245.6301. I further agree that my insurance company will be the primary source of coverage in case of injury or illness held at or sponsored by FBCS involving my child, and I am responsible for any deductible expenses in connection with that coverage. By my signature below I agree to assume responsibility for medical bills, telephone calls, and other expenses relating to an emergency. 

By my signature below, I, hereby, for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against FBCS and its agents, employees, representatives, successors, and assigns for any and all injuries suffered by myself or my child arising out of the below named Activity (program, outing, event, and/or sport) sponsored or hosted by FBCS.

I, as well, warrant I have the right to authorize the foregoing and do hereby agree to hold FBCS harmless of and from any and all liability of whatever nature which may arise out of or result from such participation. By signing this agreement, I hereby attest to and represent that I am legally permitted to enter into this agreement on my own behalf or on behalf of the child named as a participant.

For the consideration stated above, I further agree in the event the participant should make any claim against FBCS for damages arising out of church-sponsored or church-hosted program, outing, event, and/or sport, I will personally indemnify, defend, and hold harmless FBCS and its agents, employees, representatives, successors, and assigns against any and all loss and damage occasioned thereby, including attorney’s fees.

I have read and understand this agreement and have willingly placed my signature below as evidence of my acceptance of all the conditions contained herein.

Today's date: January 24, 2022

First Participant's Name

First Name*

Middle Name

Last Name*

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Third Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Fourth Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Fifth Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Sixth Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Seventh Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Eighth Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Ninth Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
Tenth Participant's Name

First Name*

Middle Name

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Additional Information

Insurance Company's Phone Number

Policy Holder's Name

Physicians Name

Physician's Phone 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

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

Age:

List below all known medical conditions, including food allergies, drug allergies, and any other medical allergies (bee stings, poison ivy, etc.) In addition, list any over-the-counter and/or prescription drugs taken regularly.
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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