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2025/2026 HBC Student Ministries Medical Release Form
This form is required for every student who desires to participate in any youth activity with Heritage Baptist Church.
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1st Child's First Name *
1st Child's Last Name *
1st Child's Grade *
for 2025/2026 school year
1st Child's Birthday *
MM
/
DD
/
YYYY
2nd Child's First Name (Legal)
2nd Child's Last Name
2nd Child's Grade
for 2025/2026 school year
2nd Child's Birthday
MM
/
DD
/
YYYY
3rd Child's First Name (Legal)
3rd Child's Last Name
3rd Child's Grade
for 2025/2026 school year
3rd Child's Birthday
MM
/
DD
/
YYYY
4th Child's First Name (Legal)
4th Child's Last Name
4th Child's Grade
for 2025/2026 school year
4th Child's Birthday
MM
/
DD
/
YYYY
Parent's First & Last Name *
Email Address *
Cell Phone Number *
ex: 4342376505; If none, list "N/A"
Secondary Cell Phone Number
Street Address *
State *
Virginia = Va
City *
Zip Code *
Has any of your contact information changed since last year? *
Name of Emergency Contact *
Emergency Contact Telephone Number (Day)
ex. 434-333-4444
Emergency Contact Telephone Number (Evening)
List allergies or medical conditions *
If none, list "N/A"; For multiple children: list name and then condition
Do you authorize HBC to approve medical treatment *
Participant(s) covered by personal/family medical insurance? *
If yes, name of insurer *
If no, list "N/A"
Policy or Group Number *
If none, list "N/A"
Participation Agreement *
I acknowledge that participation in the activity described above involves risk to me (and parent/guardian if minor), and may result in various types of injury including, but not limited to, the following: sickness, including bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activity described above, I, (or parent/guardian) acknowledge and accept the riks of injury or infection associated with participation in and transportation to and from the activity. I, (or parent/guardian) accept personal financial responsibility for any injury or other loss sustained during the activity or during the transportation to and from the activity, as well as for any medical treatment rendered to me, the participant that is authorized by Heritage Baptist Church or its agents, employees, volunteers,  or any other representatives (collectively referred to hereinafter as “Activity Sponsor”). Further, I (or parent/guardian) release and promises to indemnify, defend, and hold harmless the Activity Sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the Activity Sponsor, myself, or otherwise.    If a dispute over this agreement or any claim for damages arises, I (or parent/guardian), on my own behalf and on behalf of my minor child, waive all rights to a jury and bench trial(s) and agree to resolve the matter through a mutually acceptable alternative dispute resolution process. If I (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to and resolved by binding arbitration pursuant to the most recent set of arbitration procedures adopted by the American Arbitration Association.
Electronic Signature *
Full Legal Name
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