2018-2019 Permission & Waiver Form
Brushy Creek Baptist Church, Taylors
Email address *
Student Name
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Phone Number (xxx-xxx-xxx)
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Insurance Provider
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Policy Number
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Allergies
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Current Medications
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Other Conditions
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Electronic Signature
I acknowledge that the student above desires to participate in programs, events, or activities (herinafter collectively referred to as "activities") operated, sponsored, or attended by Brushy Creek Baptist Church (herinafter referred to as the "church").

I acknowledge that participating in the activities operated, sponsored, or attended by the Church will involve transportation to and from various locations.

I hereby give consent for the above student to participate in the various activities and authorize the Church to transport the above student to and from various locations for the activities.

I gave permission for the above student to ride in any vehicle, deemed suitable by the adult in whose care the above student has been entrusted, while attending and participating in activities operated, sponsored, or attended by the Church.

In the event that the above student is injured while participating in activities or while being transported, I do hereby authorize and consent to any X-ray; examination; anesthetic; medical, surgical, or dental diagnosis or treatment; and hospital care rendered under the general supervision and the advice of any physician or dentist licensed under the provisions of the Medical Practice Act 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.

I acknowledge the undersigned shall be liable and agree to pay all costs and expenses incurred in connection with any such medical and dental services rendered to the above student pursuant to this authorization.

I understand that should it be necessary for the above student to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

In consideration of the Church allowing the above student to participate in activities, I do hereby release and forever discharge the Church, their officers, director, employees, agents, and any parties volunteering on behalf of the Church from all actions, claims, damages, costs, expenses, or transportation to or from activities.

As the undersigned, I understand it is my responsibility to update the Emergency Information contained in the permission and Medical Release Form if necessary.

I consent and give my permission for the Church to use any photographs and/or videotapes of the above student for use in any promotional material for the Church including the Church's website.

I understand that strobe lighting may be used during special events or services at youth conferences.

Check Box for agreement with terms *
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Emergency Contact Name
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Emergency Contact Number (xxx-xxx-xxxx)
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Typed Electronic Signature
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