Preteen Retreat Registration
Date: Friday, February 16, 2018
Time: 6:00 pm - 10:00 pm
For: 4th-6th grade.
Cost: $20 per student - includes a long sleeve t-shirt, food, and jump time at Ultimate Air.

*Registration Closes February 7, 2018

We will be focusing on how to follow God's directions for our life. We will start at 6:00PM with worship in the Skybox, eat dinner, and then end the night at Ultimate Air from 9:00-10:00PM.

Parent pickup will be at Ultimate Air at 10PM.

Participant information
Please include multiple children on the same form.
Name(s) *
Your answer
Age(s) *
Your answer
Birthdate(s) *
Your answer
Address *
Your answer
School *
Your answer
Grade(s) *
T-shirt size(s) *
Any allergies or medical conditions? *
Your answer
Parent Contact Information
Name(s) *
Your answer
Cell number(s) *
Your answer
Email address(es) *
Your answer
Emergency Contact Information
Just in case Parent/Guardians can't be reached
Name *
Your answer
Phone Number *
Your answer
Parental Consent
I(We), the undersigned, do hereby give permission for my (our) child, (named above) to attend and participate in activities sponsored by First Baptist Church of Jonesboro.

I (We) authorize and adult, in whose care the minor has been entrusted, to consent to any x-ray, examination, anesthetic, medical, surgical, dental diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act and on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for the above named minor to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by First Baptist Church of Jonesboro.

Liability Release
In consideration for being accepted by First Baptist Church for participation in activities with its ministries, I (we), being 21 years of age or older, do for myself (ourselves) and on behalf of my child-participant if said child is not 21 years of age, release, forever discharge and agree to hold harmless First Baptist Church of Jonesboro and its agents from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in an event, trip or activity with First Baptist Church.
Furthermore, I (we) on behalf of my (our) child-participant (if under the age of 21) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.
Furthermore, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.
The undersigned further hereby agrees to hold harmless and indemnify First Baptist Church, its agents, directors and employees for any liability sustained by said church as the result of negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.
For participants under 21 years of age: I (We), as the parent(s) or legal guardian(s) of this participant, hereby grant my (our) permission for him/her to participate fully in activities with First Baptist Church and hereby give my (our) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including, but not limited to emergency surgery or medical treatment. I (we) also assume all responsibility for medical bills that may result, if any. Furthermore, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I (we) hereby assume all transportation costs.
*
Required
Insurance/Medical Information
Physician Name *
Your answer
Physician Phone Number *
Your answer
Insurance Company *
Your answer
Policy # *
Your answer
Group # *
Your answer
Photographic Release for a minor child
I, (child’s parent/legal guardian named above), grant First Baptist Church (FBC) the right to use and display any photographs or video taken of the minor under my supervision, regardless of when taken, for the purpose of promoting, advertising, describing, or offering information on the activities and ministries of FBC in all forms of media, including any publication, newsletter, newspapers, letter, other print, Internet, video, and FBC’s website.
I release any personal or proprietary right that I may have to any such photographs and video, and I release and waive any claim that I or my minor child may have, now or in the future, to any compensation or damages as a result of FBC’s use of any such photographs or video.
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