Please read the following release statement and complete the required fields. Marking the box indicating your agreement and consent, along with today's date - act as your electronic signature.

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately either myself or the emergency contact listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the ministry leader to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my child as deemed necessary by the attending physician or dentist.
I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by First Baptist Church of Brownsville, Oregon, through its accident policy will be used as a backup for what my family's insurance does not cover. I understand and agree that any expenses not covered by either my insurance or the church's insurance are my responsibility.

I understand all reasonable safety precautions will be taken at all times by First Baptist Church and its agents during events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold First Baptist Church , its leaders, employees, agents, and volunteer staff liable for damages, claims, losses, diseases, illness, or injuries incurred by the child named on this form.

I understand that if there is any change in my child's insurance coverage and information, it is my responsibility to provide the new information to the church as soon as possible.

This release statement is in effect from September 1, 2022 to August 31, 2023.

I give my permission for my child's picture to be used in club displays. Also, I give my permission for a leader to phone and send cards to my child.