Parent/Guardian Name *

This form must be filled out by the child's legal parent or guardian.

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Cell Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent *

I understand that neither Bethel Baptist Church nor the insurance company will be responsible for medical treatment or liability resulting from physical conditions existing prior to my child(ren) attending VBS.

Agreed

Emergency Authorization *

I hereby give permission to the first aid personnel selected by the VBS Leadership to provide standard first aid care and administer over the counter medication, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the VBS Leadership to order x-rays, routine tests, hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child(ren) as named above.

Agreed

Hold Harmless Agreement *

Furthermore, as the parent or guardian for a minor child(ren) as named above who is in my care and custody, do hereby grant permission for my child to attend a program or event at Bethel Baptist Church. I fully understand the nature of recreational activities associated with the use of the church facilities and/or programs includes risk of danger, which may result in personal injury or harm to my child. I understand that my child will be under adult supervision at all times but, notwithstanding any level or degree of supervision, that accidents may occur which may result in physical injury or harm to my child. It is with the full understanding of the risks associated with these types of activities that I grant permission for my child to participate in the program to be conducted at Bethel Baptist Church, and I agree to indemnify and hold harmless Bethel Baptist Church, its staff, directors, employees, agents and/or representatives from any claim for any injury or damage which may result from my child’s attendance and participation in the VBS program conducted on church property.

Agreed

Permission *

Permission is granted for my child to participate and I understand that by signing this form I am voluntarily and knowingly accepting responsibility for my child’s participation in the activity or program to be conducted at Bethel Baptist Church.

Agreed

Photos *

I grant permission for pictures and images of my child to be taken while participating in activities and used for Bethel Baptist Church promotional purposes.

Agreed