Student Consent Form Beach Camp

I, the undersigned parent or guardian, hereby consents to my child, participating in the activities connected with Lakeside Baptist Church. I certify that my child is able to participate in these activities, including sports. If my child has medical conditions, which may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached within a reasonable period of time, I hereby authorize the adult sponsor(s) to make emergency medical decisions for my child. If there are any activities, I do not want my child to be involved in, I have listed them below.

Please select what event you are registering for? *

Participant's Name:

Age

Address:

City:

Home Phone:

Email *

example@example.com

State:

Zip

Emergency Number:

Medical Conditions / Allergies:

Physical Restrictions:

Instructions and Medications:

Date of last tetanus or booster:

Date

I do NOT wish my child to participate in the following:

Emergency Telephone Numbers and Name of Person to Contact:

Name:

Parent/Guardian Name:

Daytime Phone:

Evening Phone:

Cell Phone:

Second Contact:

Phone:

Insured Name:

Insurance Company or Group#:

Policy Number:

Policy Holder's DOB:

Authorization for Medical Treatment I hereby give Lakeside Baptist Church permission to have my child treated in case of an accident.

IUNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT

THERETO. I do hereby agree to hold Lakeside 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. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive aspermitted by the law of the State of Alabama and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full 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. Consent to Use and Publication of Image I hereby give Lakeside Baptist Church the absolute, unconditional, and irrevocable right and permission to use Participant's name and to use, reproduce, edit, project, display, copyright, and publish, photographic images and/or moving pictures and or videotaped images of my child (the participant), with or without voice, in which the participant are included, in the whole part, photographed, taped, videotaped, and/or recorded prior to, during, and/or after the event, and to circulate same in any and all forms and media for are, advertising, trade purposes, and competition, of every description and any other lawful purpose whatsoever, and I hereby consent to the use of all printed matter in conjunction therewith waive all rights to inspect and/or approve drafts, finished products, and/or editorial, promotional, and printed copy, and sound tracts that may be used in conjunction therewith, and waive all rights to control any aspect of any production, alteration, use, distribution, or disposition of said products, copy, and/or soundtracks, and hereby discharge and agree to hold Lakeside Baptist Church harmless and fully indemnify Lakeside Baptist Church from and against any and all Claims arising by virtue of any production, alteration, use, distribution, or disposition thereof, and from against all Claims arising by virtue of any blurring, distortion, alteration, optical illusion or use in composite form, whether intentional or otherwise, that may occur or be produced in the production, processing, duplication, projecting, or displaying of said images of me and/or Participant, and from any and all Claims for violation of any personal and all proprietary rights of that I or Participation with images and with the production, alteration, use, distribution, and disposition thereof. Release of All Claims

Ifurther state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. I am expecting my child to be obedient to all leadership and I understand that if my child does not behave I will be expected to come and pick him or her up. There will not be any drugs, alcohol, tobacco, fireworks, or weapons of any kind allowed on this trip. If my child is caught with one or more of these items I will be immediately called to come get my child. This is a legally binding agreement, which I have read and understand.

Signature of Parent or Guardian: *

Clear

Signature of Student: *

Clear

Date