2017/2018 HBC Student Ministries Medical & Media Release Form
This form is required for any student who desires to participate in any youth activity for the year of August 2017 through August 2018 and is to be filled out for each school year for Heritage Baptist Church activities.
1st Child's First Name (Legal) *
Your answer
1st Child's Last Name *
Your answer
1st Child's Grade *
for 2017/ 2018 school year
1st Child's Birthday *
MM
/
DD
/
YYYY
2nd Child's First Name (Legal)
Your answer
2nd Child's Last Name
Your answer
2nd Child's Grade
for 2017/2018 school year
2nd Child's Birthday
MM
/
DD
/
YYYY
3rd Child's First Name (Legal)
Your answer
3rd Child's Last Name
Your answer
3rd Child's Grade
for 2017/2018 school year
3rd Child's Birthday
MM
/
DD
/
YYYY
4th Child's First Name (Legal)
Your answer
4th Child's Last Name
Your answer
4th Child's Grade
for 2017/2018 school year
4th Child's Birthday
MM
/
DD
/
YYYY
Parent's First & Last Name *
Your answer
Email Address *
Your answer
Cell Phone Number *
ex: 4342376505; If none, list "N/A"
Your answer
Street Address *
Your answer
State *
Virginia = Va
Your answer
City *
Your answer
Zip Code *
Your answer
Has any of your contact information changed since last year? *
Name of Emergency Contact *
Your answer
Emergency Contact Telephone Number (Day)
ex. 434-333-4444
Your answer
Emergency Contact Telephone Number (Evening)
Your answer
List allergies or medical conditions *
If none, list "N/A"; For multiple children: list name and then condition
Your answer
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"
Your answer
Policy or Group Number *
If none, list "N/A"
Your answer
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, 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 risks of injury 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.
Media Release *
I give permission to Heritage Baptist Church (HBC) to use media taken of myself and/or my child in the following ways: a) To copyright the media in HBC’s name or any other name that HBC chooses; b) To use and publish the media, in any form and for any purpose, including, but not limited to, illustration, promotion, production, and c) choose the option below:
Media Release *
If the person is under age 21, a parent or guardian must provide consent below. I give permission for images of my child, captured at Heritage Baptist Church through video, photo, and digital mediums to be used solely for the purposes of Heritage Baptist Church’s promotional material and publications, and waive any rights of compensation or ownership.
Electronic Signature *
Full Legal Name
Your answer
Submit
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