Centerville Baptist Church Youth: General Permission and Liability Form
Centerville Baptist Church, 908 Centerville Turnpike S, Chesapeake, VA 23322, 757-482-4466
Youth name *
Youth Date of Birth:
Home address: *
Home phone: *
Current grade in school: *
Primary Parent/Guardian Name (s) and cell phone numbers: *
Parent/Guardian address (if different)
Alternate Emergency Contact(s) name and cell phone: *
Medical conditions, if any:
List of food allergies, if any:
Medications (name, dosage, purpose):
Over the counter medications allowed to take:
Does the youth wear contact lenses?
Clear selection
Medical Insurance information (company name, responsible party name, policy number, group number, address and phone number of company)
Personal property waiver: I understand that it is my responsibility to safeguard any personal property I bring. I further understand that Centerville Baptist Church will not under any circumstances be responsible for any property lost, misplaces, or stolen. *
Photo/Video Notice: I understand that as a participant, my child may be photographed or videod during normal activities and that these photographs or videos may be used in other event or church materials and/or posted on the church website or social media page. *
General Permission (please read and type your name as a signature and acknowledgement at the bottom): I give the participant listed on this form permission to participate in Centerville Baptist Church ministry events and outings. I realize that this is a general form to be placed on file in the church ministry office for church use when deemed necessary. As the parent/guardian of the participant, I certify that the information provided on this form is correct to the best of my knowledge. In order for appropriate diagnosis and prompt treatment in the event of a medical emergency, I give permission for such diagnostic, therapeutic, and operative procedures as may be deemed medically necessary for treatment of the herein named participant. I assume financial responsibility for medical expenses incurred in the transport and treatment of the participant. I also assume financial resonsibility for expenses incurred in returning the participant home for any of the folllowing reasons: substance abuse, endangering the life of another person, sexual misconduct, illegal activity or other continual disruptive behavior. I understand that each individual is responsible for his/her own insurance coverage during any trip. I hereby release and forever discharge Centerville Baptist Church, its staff, all sponsors, state conventions, employees, and any designated individual in charge of any trip from any legal responsibility, financial responsibility, claims, demands, actions or cause of action, past, present, or future, arising from my personal or my child's participation in any church activity. Please type your name below as acknowledgement. *
COVID-19 Policies: Centerville Baptist Church has implemented safetly measures to prevent the transmission of COVID-19. However, I understand that Centerville Baptist Church is not reponsible for the transmission of COVID-19 at any event sponsored by or related to Centerville Baptist Church. It is the responsibility of the parent/guardian to keep their child away from any CBC events if they have been sick or have been exposed to COVID-19. Safety measures are as follows: Non-Worship Gatherings may be limited based on current state guidelines on Centerville grounds. Masks must be worn during youth events, inside and outside of the building. Entrances/exits will be limited; please abide by guidelines provided. Please utilize designated restrooms only. Social distancing is required: please maintain at least 6 feet from others not in your household. Upon arrival, please sanitize hands. For outdoor events, please provide your own chairs. *
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