2021 SBC Youth On Mission Registration/Release Form

SBC 2021 YOUTH ON MISSION REGISTRATION & RELEASE

7th - 12th grade completed May/June 2021
Child's Name *

First Name Last Name
Birth Date *
MM/DD/YYYY
Grade completed as of June 2021 *
Address
Street Address
City
State
Zip Code
Father's Name *

First Name Last Name
Father's Cell Phone Number *

Area Code Phone Number
Text? *

Yes No
Mother's Name *

First Name Last Name
Mother's Cell Phone Number *

Area Code Phone Number
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: *

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

Yes No
PLEASE NOTE:

WORKERS WILL NOT ADMINISTER ANY MEDICATION
HAS CHILD HAD ANY OF THE FOLLOWING:
Chicken Pox *

Yes No
Fainting spells *

Yes No
Heart trouble *

Yes No
Asthma *

Yes No
Seizures *

Yes No
Diabetes *

Yes No
In consideration for your agreeing to accept the above named child as a 2021 SBC Youth on Mission participate, I hereby give my authority and consent to medical treatment as may be needed in the judgment of the treating physician, for my child by a physician chosen by the Emergency Medical Technician working for the Southern Baptist Convention. I further relinquish all claims against, and will not hold liable the coordinators, teachers, or any interested parties, including the Youth on Mission program, for any accidents or for obtaining medial treatment for my child.
Electronic signature: Please sign and date here: *

Signature Date
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.
Current Date: *

Month Day Year
Date
Initial to give permission
Initial to NOT give permission
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 Florida 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 and Payment Information
Note: There is a one-time, non-refundable, registration fee of $10 per child

This form is only for those that have completed 7th-12th grade

by May/June 2021

Program fee: $55 per child
SBC Annual Meeting (Tue-Wed) ONLY
prev next ( X )
Registration Fee $ 10.00

Youth on Mission $ 55.00

Total $ 0.00
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 A COPY OF COMPLETED FORM BEFORE SUBMITTING
Should be Empty:

SBC 2021 YOUTH ON MISSION REGISTRATION & RELEASE

EMERGENCY & MEDICAL INFORMATION

HAS CHILD HAD ANY OF THE FOLLOWING:

Photo/Video Release

Sessions and Payment Information

PLEASE PRINT A COPY OF COMPLETED FORM BEFORE SUBMITTING