2021 Solid Rock Medical, Liability, And Media Release Form

Student's Name*

First NameLast Name

Student's Cell Phone Number

Area CodePhone Number

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

MonthDayYear

Parent/Guardian #1 Name*

First NameLast Name

Parent/Guardian #1 Email*

example@example.com

Parent/Guardian #1 Cell Phone Number*

Area CodePhone Number

Parent/Guardian #2 Name

First NameLast Name

Parent/Guardian #2 Email

example@example.com

Parent/Guardian #2 Cell Phone Number

Area CodePhone Number

In case of an emergency, we will contact the following people if parent/guardian cannot be reached. Please provide an additional emergancy contact information other than the Parent or Guardian listed in section 1.

Emergency Contact #1: Name*

First NameLast Name

Emergency Contact #1: Cell Phone Number*

Area CodePhone Number

Emergency Contact #1: Relationship To Student*

Emergency Contact #2: Name

First NameLast Name

Emergency Contact #2: Cell Phone Number

Area CodePhone Number

Emergency Contact #2: Relationship To Student

Student's or Family Physician

Physician's Phone Number

Medical Insurance Company*

Policy Number*

Member's Name*

Photo of Front of Insurance Card*

Photo of Back of Insurance Card*

Allergies (please list all or put "n/a" if none)*

Medication (please list all or put "n/a" if none)*

Dietary Restrictions (please list all or put "n/a" if none)*

I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said student to attend and participate in the events and activities Solid Rock Youth Ministries, both on and off church grounds, including the necessary transportation to and from these events and activities.

Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-being of the student affected; (3) I cannot be personally contacted.

I further agree not to hold Carrollton First Methodist Church (CFMC) or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless CFMC for all claims made and liabilities assessed against them as a result of any event or activity. I release CFUMC and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity.

Furthermore, I understand and assume the expenses of any property damage caused by my student. Should it be necessary that my student be returned home due to disciplinary action (when on trips), I will be contacted by the leaders and will be responsible to pick my student up and assume the cost of transportation.By signing below, I am acknowledging that I have read through and understand the above statements.

By checking the box below, the Parent and/or Guardian listed above in section 1 "General Information" of this form acknowledges that they have read through, understand and agree to the Liability Release statements above.*

I Agree

Today's Date

MonthDayYear

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which Carrollton First Methodist Church ("CFMC") adheres to comply.

In consideration of my participation in the activities/events of CFMC, I (the undersigned) acknowledge and hereby declare the following:

My student and I am aware of the existence of the risk on my physical appearance to the venue and my participation to the activity of CFMC that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.My student is fully and personally responsible for their own safety and actions while and during may participation and I recognize that my student may be in any case be at risk of contracting COVID-19.With full knowledge of the risks involved, I hereby release, waive, discharge CFMC, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.I agree to indemnify, defend, and hold harmless CFMC from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Signature

Today's Date

Date

I give permission for Carrollton First Methodist Church and its volunteers and staff to photograph, videotape and/or voice record my child/children (or allow area news reporters to do the same) for purposes of in-house church use and/or for public information for promotion of the church (i.e. brochures, websites, newspapers, radio, television, etc...)

By checking the box below, the Parent and/or Guardian listed in section 1 "General Information" of this form acknowledges that they have read through and agrees to the Media Release statement above.*

I Agree

General Information

Emergency Contact

Medical Information

Liability Release

COVID-19 Liability Release

Media Release