Beach Retreat Student Ministry Parental Consent, Certification, and Medical Authorization Form

2022 Beach Retreat 7th-12th Grade

Parental Consent, Certification, and Medical Authorization Form

Student's Name *

Date *

Date

Parent/Guardian Name(s) *

Email *

example@example.com

Phone

Doctor's Name

Phone

Health Ins. Contract #

Member ID

Insurer

Known Allergies

List any medication or drugs taken regularly

Local Relative or Friend in case Parents cannot be located

Please upload copy of BOTH sides of your medical insurance card below.

Front of insurance card:

Back of insurance card:

Permission to Participate in Lakeside Baptist Activities

As the parent (or legal guardian), I the undersigned, certify that my student, named above, has my express permission to participate in all activities, of any nature, sponsored by Lakeside Baptist Church for the calendar year.

Assumption of Risk

I acknowledge that there are certain risks associated with participation in any activity or program, including transportation accidents, injuries, loss of personal items, criminal actions beyond the control of Lakeside Baptist Church, or other harm that may occur to my student. I assume the risk associated with such activities and release Lakeside Baptist Church of any liability for such.

In Case of a Medical Emergency

It is my understanding that a church representative will attempt to notify me in case of a medical emergency involving my student. If the church cannot reach me, then I authorize the church representative to hire a doctor or other health-care professional, and I give my permission to the doctor or other health-care professional to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred. I will notify the church if I feel there are any health considerations that would prevent my student's participation in an activity. I also give my permission for church leaders to restrict my student from participation in any activity, which they have any question about for health or other reasons.

Photo/Video Consent

I grant and convey to Lakeside Baptist Church all right, title, and interest in any and all photographic images, video, or audio recordings made during my student's participation in Lakeside Baptist Church events, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

I give permission for photographs and videos of my student, taken while in church functions and events, and for special emphases to be placed Baptist Church publications printed and digital. on Lakeside Facebook Page and other social media.

I do NOT give permission for photographs and videos of my student, taken while in church functions and events, and for special emphases to be placed: digital; i I do NOT Lakeside Baptist Church publications printed and digital. I do NOT on Lakeside Facebook Page and other social media.

Dispute Resulution Agreement

Lakeside Baptist Church believes that the Bible commands Christians to make every effort to live at peace and to resolve disputes with each other in private or within the Christian church (see Matthew 18:15-20; 1 Corinthians 6:1-8 Therefore, any dispute, not otherwise released or for which the risk was not assumed, arising from or related to allegations by or against workers, employees, volunteers, church members or their families, will be submitted to biblically based conciliation in accordance with the Rules

of Procedure for Christian Conciliation. (A complete text of the Rules is available at ttp://www.hispeace.org/html/geticrul.htm That forum provides the best opportunity for resolving issues in a fair manner while seeking to preserve or restore the relationships fractured by the dispute and allowing the Church to continue its ministry to all people.

Parent/Guardian Name (Printed) *

LAKESIDE BAPTIST CHURCH