LFBC Disciple Now 2019
DNow Registration
Name *
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Address (Include City, State and Zip) *
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Phone # *
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Email address *
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Grade *
T-Shirt Size *
Any allergies or medication? *
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Emergency Contact Name and Number *
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I understand the cost of DNow is $25. *
Permission For Treatment and Photo/Video Notice: My permission is granted for Locust Fork Baptist Church director, church official, or any staffer or adult present or in charge of First Aid, to obtain necessary medical attention in case of sickness or injury to the participant. Also, I understand that as a participant, my child may be photographed or videotaped during normal activities and these photos/videos may be used in promotional materials. *
The undersigned participant and/or parent or legal guardian of the participant hereby releases, acquits and forever discharges Locust Fork Baptist Church, their employees, agents, successors, and assigns, from all suits, damages, claims, proceedings, demands, and liability from any such injury, harm or damage that the participant may incur during any participation in this event. It is further agreed that the participant and/or the parent or legal guardian of the participant shall indemnify and hold harmless Locust Fork Baptist Church, their employees, agents, successors, or assigns, and host families from all claims of any nature whatsoever, whether in the form of legal or equitable actions that can be brought as a result of the participant’s own negligence while participating in the activity described herein. Furthermore, in the event of an accident, if the said staff or representatives are unable to communicate with the participant or contact the parent or legal guardian of the participant, the participant or the undersigned parent or guardian of the participant hereby grants permission to said staff or representative to administer necessary first aid, and/or to take the participant to the nearest medical facility for additional treatment.  *
To complete the form please print name and date below (youth under 18 years of age requires parent/custodial signature) * *
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