Name *

First Name

Last Name

Birthdate

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Name

First Name

Last Name

Phone

(###)

###

####

To Grant Consent to Ride *

I hereby give my consent for my child to ride transportation provided by Fellowship Baptist Church.

Yes

No

To Grant Consent for Medical Treatment *

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the designated physician or dentist, or in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of child to the designated hospital or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Yes

No

Liability Release *

I do hereby agree to hold Fellowship Baptist Church and its agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with participation in activities and programs.

Yes

No

Photo/Video Release *

I do hereby grant permission for my child to be photographed, video-recorded and/or audio recorded for the possible use for media purposes.

Yes

No