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7600 Studley Road, Mechanicsville, VA 23116

Phone: (804) 746-4952   Fax: (804) 746-7287

Website: www.northsidebaptist.church


Activity Participation & Liability Waiver -

Family Ministries

My child has permission to attend all church-sponsored children and/or youth activities communicated by Northside Baptist. NOTE: If it is your desire to limit your child’s participation in any event, please submit your wishes in writing to Northside Baptist Church of Mechanicsville Virginia, Inc. (hereafter referred to as 'Northside') prior to that event.


Waiver and Liability Form

I (We) acknowledge that my child’s participation in an activity sponsored by Northside is voluntary and may require involvement in activities that require traveling or physical exertion. Therefore, in consideration of my child’s being allowed to participate in our church program activities, I (we) agree to the following: (Please initial below.)

Northside is not responsible for the loss or theft of personal belongings.

I understand and authorize that my child’s image may be photographed or filmed and used in video presentations, printed publications and the annual photo directory, including the church’s internet website. 

I hereby take the following action for my child, myself, my executors, administrators, heir, next of kin, successors and assigns: (1) I waive, release and discharge from any and all claims or liabilities for death or personal injury damages of any kind, which arise out of or relate to my child’s participation in Northside activities; (2) I indemnify and hold harmless Northside and its staff and volunteers from any claims made or liabilities assessed against them as a result of my child’s actions. 

I hereby assume the risks of my child participating in all activities sponsored by Northside. The undersigned parent or guardian of (the minor), hereby executes this document for and on behalf of the minor named herein. I agree to indemnify and hold harmless the person or entities mentioned above from any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Waiver and Release.

I hereby authorize any licensed physician, emergency medical technician, hospital or other medical health care facility to treat the minor named herein for the purpose of attempting to treat or relieve any injury received by said minor. I authorize any such Medical Provider to perform all procedures deemed medically advisable in attempting to treat or relieve such injuries. I consent to the administration of anesthesia as deemed advisable. I realize and appreciate that there is a possibility of complications and unforeseen consequences of any medical treatment, and I assume any such risk for and on behalf of myself and said minor. I understand that attempts will be made to contact me in the most expeditious way possible. Permission is also granted to the representative of Northside to provide the needed emergency treatment to the child prior to his/her admission to a medical facility.

Parent/Guardian Signature:

Date: June 28, 2022


First Child's Name

First Name*

Middle Name

Last Name*
First Child's Date of Birth*
I certify that I am 18 years of age or older
First Child's Information

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
First Child's Signature*
Second Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Second Child's Signature*
Third Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Third Child's Signature*
Fourth Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Fourth Child's Signature*
Fifth Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Fifth Child's Signature*
Sixth Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Sixth Child's Signature*
Seventh Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Seventh Child's Signature*
Eighth Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Eighth Child's Signature*
Ninth Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Ninth Child's Signature*
Tenth Child's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
Tenth Child's Signature*
Parent/Guardian 1 Information

First Name *

Last Name *

Cell Phone: *

Work Phone:
Parent/Guardian 2 Information

First Name *

Last Name *

Cell Phone *

Work Phone
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 be added to our monthly email
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.
Parent or Guardian's Name

First Name*

Middle Name

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

Birthday *

Grade *

Allergies:


Drug allergies (specify): *

Food allergies (specify): *

Any other allergies/allergic reactions: *

Current Medications:


Medication name:

Dosage:

Reason for taking:
Can we administer the following over-the-counter medications? Check all that are acceptable:
Acetaminophen (Tylenol)
Antacid
Ibuprofen (Advil)
Benadryl
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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