BIBLE CHALLENGE 2021-2022

BIBLE CHALLENGE WEDNESDAY NIGHTS

BEGINS OCTOBER 6 | 6:30pm-8:00pm
Please fill out a separate form for each child who is attending
Child's Name
Last Name
Gender

Male Female
Current Grade
Age
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
First & Last Name
Phone Number
Alt. Phone Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name
Relationship
Phone Number
Emergency Contact's Name
Relationship
Phone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe
Please list all persons authorized to pick up your child and their relationship to the child. (John Doe-neighbor). In the event it is not a parent, please note a valid I.D. will be required at sign out.
Please list all persons your child is authorized to contact (should the need arise) and their relationship the child. Please also include a contact number.
Informed Consent and Acknowledgement
I hereby give my approval for my child’s participation in any and all activities prepared by First Missionary Baptist Church during the selected Wednesday Night Bible Challenge period. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless {First Missionary Baptist Church} . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising during the Bible Challenge sessions. In case of injury to said child, I hereby waive all claims against {First Missionary Baptist Church} . including all leaders and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization
As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.Permission is also granted to the (First Missionary Baptist Church) and its affiliates, including leaders and teachers, to provide the needed emergency treatment prior to the child’s admission to the medical facility.
I would like my child to wear a wrist band identfying allergies, severe medical issues, or any other special need

YES NO
Release authorized on the dates and/or duration of the registered Bible Challenge.This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
It is okay to post photos or videos of my child on social media connected to Bible Challenge and First Missionary Baptist Church.
Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE
Signature *

Clear
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BIBLE CHALLENGE WEDNESDAY NIGHTS

Parent/Guardian Information

Emergency Information

Informed Consent and Acknowledgement

Medical Release and Authorization

Confirmation