2021 SBC Preschool Childcare Registration/Release Form

SBC PRESCHOOL CHILDCARE REGISTRATION & RELEASE FORM

(ages birth through 5 years)
Child's Name *

First Name Last Name
Birth Date *
Age as of June 2021 *
Street Address
City
State
Zip Code
Father's Name *

First Name Last Name
Father's Cell Phone Number *

Area Code Phone Number
Do You Text? *

Yes No
Mother's Name *

First Name Last Name
Mother's Cell Phone Number *

Area Code Phone Number
Do You Text? *

Yes No
E-mail Address where you'd like to receive information: *
EMERGENCY & MEDICAL INFORMATION
Emergency Contact Name *

First Name Last Name
Contact Phone Number: *
List food or medicine allergies: (If none, enter 'none') *
List all current medications: (If none, enter 'none') *
List chronic illness/physical limitations: (If none, enter 'none') *
Date of last tetanus shot:
Is child allergic to tetanus booster?

Yes No
We reserve the right to refuse admission to Childcare if any signs of visible illness:
Parental Agreement (initials)
PLEASE NOTE: WORKERS WILL NOT ADMINISTER ANY MEDICATION
HAS CHILD HAD ANY OF THE FOLLOWING:
Chicken Pox *

Yes No
Fainting spells *

Yes No
Diabetes *

Yes No
Asthma *

Yes No
Heart trouble *

Yes No
Seizures *

Yes No
Name of Insurance Company (if none, enter 'none'): *
Policy Number (if not applicable, enter 'none'): *
I hereby authorize the Southern Baptist Convention Leadership to make emergency medical decisions for my child and I understand that my insurance coverage will be primary coverage.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITY, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby indemnify and hold harmless the Southern Baptist Convention and each of its officers, directors, agents, employees, volunteers and representatives (the 'Indemnified Parties') from and against any and all liability, damages, actions, cause(s) of action, claims, losses and/or expenses, including but not limited to attorney's fees, court costs and expenses arising in connection with or based on injury to or death of any persons or property, including the loss or use thereof, caused in whole or in part, regardless of whether or not caused in whole or in part by the negligence of the Indemnified Parties, or any one or more of them. However, this indemnification shall not apply to willful misconduct committed by the Indemnified Parties.
PHOTO/VIDEO RELEASE
I further give permission and consent to the Southern Baptist Convention for any photographs, videotapes and interviews to be taken during the sessions to be published and used to illustrate, report, promote and advertise the event including on Internet Web Sites. I hereby assign full copyright of these photographs to the Southern Baptist Convention with the reproduction either wholly or in part. I agree that they can be used separately or together, either wholly or in part, in any way and in any medium provided my name is not mentioned in connection with any other statement or wording which may be attributed to me personally. I undertake not to prosecute or to institute proceedings, claims or demands against the Southern Baptist Convention or any of its employees related to any action of the Southern Baptist Convention taken in accordance with this paragraph.
Initial to give permission
Initial to NOT give permission
Current Date: *

Month Day Year
I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Tennessee and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I agree that in any event that I take any legal action against the Southern Baptist Convention or any other indemnified party, which is decided in favor of the indemnified party, I will be responsible for all legal fees, court costs and out-of-pocket expenses of the indemnified party, its owners and employees. 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, understood, and accept.
Electronic Signature: By entering my name below, I agree and accept the above *

First Name Last Name
SESSIONS & PAYMENT INFORMATION
Note: There is a one-time, non-refundable, registration fee of $10 per child

This form is only for ages birth through 5 years

$25 per child, per event (SBC Pastors' Conference-Sunday, Monday or

SBC Annual Meeting-Tuesday, Wednesday)

$6 per child, per day for lunch (Monday, Tuesday, and/or Wednesday)

If child will be staying during the lunch time (even if not eating) you must select and pay for lunch in order that there is appropriate worker coverage
SBC Pastors' Conference (Sun-Mon) AND/OR SBC Annual Meeting (Tue-Wed)
prev next ( X )
Registration Fee $ 10.00

SBC Pastors' Conf (Sunday/Monday) $ 25.00

Lunch-Monday $ 6.00

SBC Annual Meeting (Tuesday/Wednesday) $ 25.00

Lunch-Tuesday $ 6.00

Lunch-Wednesday $ 6.00

Total $ 0.00
PLEASE PRINT A COPY FOR YOUR RECORDS BEFORE SUBMITTING
Upon completion of form, click "Submit Form and Pay". You will then be taken to PayPal where you can pay using a credit card or a PayPal account and the registration/release process will be completed. Only one child may be registered at a time.

Should you need to contact us, please e-mail us at childcare@sbc.net
PLEASE PRINT COMPLETED FORM BEFORE SUBMITTING
Should be Empty:

SBC PRESCHOOL CHILDCARE REGISTRATION & RELEASE FORM

EMERGENCY & MEDICAL INFORMATION

PLEASE NOTE: WORKERS WILL NOT ADMINISTER ANY MEDICATION

HAS CHILD HAD ANY OF THE FOLLOWING:

PHOTO/VIDEO RELEASE

SESSIONS & PAYMENT INFORMATION

PLEASE PRINT A COPY FOR YOUR RECORDS BEFORE SUBMITTING