Navigate Youth Ministry Registration and Waiver Form
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Email *
Teenager's Name (first and last) *
Age *
Address (including city, state, zip) *
Parent's (or legal guardian) Name(s) *
Cell phone number(s) *
Okay to receive occasional texts at the above number(s)? *
๐— ๐—ฒ๐—ฑ๐—ถ๐—ฐ๐—ฎ๐—น ๐—œ๐—ป๐—ณ๐—ผ๐—ฟ๐—บ๐—ฎ๐˜๐—ถ๐—ผ๐—ป
Please list all pertinent information so that we can best be prepared to help your child
Special Medication
Allergies (including severity of reaction and treatment)
Physical handicaps, disorders, diseases
Restrictive activities (including reason)
Date of last tetanus shot
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DD
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YYYY
Insurance company *
Policy number *
Address *
Insurance phone number *
MEDICAL AUTHORIZATION: In case of Medical Emergency, I hereby give my permission to the staff member in charge to hospitalize and/or secure the services of a licensed physician, surgeon,or anesthetist in providing the necessary care for my child as named on this application. I certify that my child is in good physical condition and is able to participate in the entire ๐—ก๐—”๐—ฉ๐—œ๐—š๐—”๐—ง๐—˜ ๐—ฌ๐—ผ๐˜‚๐˜๐—ต ๐— ๐—ถ๐—ป๐—ถ๐˜€๐˜๐—ฟ๐˜† program except for the activities listed as โ€œrestricted."                               ๐—ง๐—ผ ๐—ฎ๐˜‚๐˜๐—ต๐—ผ๐—ฟ๐—ถ๐˜‡๐—ฒ, ๐˜๐˜†๐—ฝ๐—ฒ ๐—ฝ๐—ฎ๐—ฟ๐—ฒ๐—ป๐˜'๐˜€ ๐—ป๐—ฎ๐—บ๐—ฒ ๐—ฏ๐—ฒ๐—น๐—ผ๐˜„. *
I, the undersigned parent or guardian, hereby consent for my child to participate in the ๐—›๐—ฒ๐—ฟ๐—ถ๐˜๐—ฎ๐—ด๐—ฒ ๐—•๐—ฎ๐—ฝ๐˜๐—ถ๐˜€๐˜ ๐—–๐—ต๐˜‚๐—ฟ๐—ฐ๐—ต ๐—ผ๐—ณ ๐—ช๐—ฎ๐—น๐—น๐—ถ๐—ป๐—ด๐—ณ๐—ผ๐—ฟ๐—ฑ, ๐—–๐—ง, ๐—ก๐—”๐—ฉ๐—œ๐—š๐—”๐—ง๐—˜ ๐—ฌ๐—ผ๐˜‚๐˜๐—ต ๐— ๐—ถ๐—ป๐—ถ๐˜€๐˜๐—ฟ๐˜† (the "Ministry") activities from September 1, 2021 through August 31, 2022. I certify that my child is able to participate in physical activities as directed by Ministry youth workers. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them on the registration form above. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize Pastor Robert Treloar or Mrs. Anna Treloar to make emergency medical decisions for my child. If there are any activities in which I do not want my child to be involved, I have listed them on the registration form.I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED DURING THE PROGRAM, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold Heritage Baptist Church and its agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities. On March 11, 2020, the World Health Organization declared the novel coronavirus, COVID-19, a pandemic. COVID-19 is highly contagious and known to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people over the past several weeks. By attending Heritage Baptist Church, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you and your family may be exposed to or infected by COVID-19. You also acknowledge that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of yourself and/or others, including, but not limited to, Ministry employees, contractors, volunteers, members, and participants and their families. You agree to assume all the foregoing risks, waive liability against the Ministry and any other listed parties, and accept sole responsibility for any illness, injury, disability, or death to you or your family, including all claims that may arise resulting from any of these. I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by law of the state of Connecticut and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full and legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.                                                                                     ๐—ง๐—ผ ๐—ฎ๐—ด๐—ฟ๐—ฒ๐—ฒ, ๐˜๐˜†๐—ฝ๐—ฒ ๐—ฝ๐—ฎ๐—ฟ๐—ฒ๐—ป๐˜'๐˜€ ๐—ป๐—ฎ๐—บ๐—ฒ ๐—ฏ๐—ฒ๐—น๐—ผ๐˜„. *
A copy of your responses will be emailed to the address you provided.
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