Funeral Packet

Please complete this form if you wish to have a funeral at Hickory Withe Baptist Church.

Usage Charge = FREE

• There is no usage charge for church members to use the church facilities for a funeral or memorial service.
• Please contact the Church Office (901-465-8043) to ensure the time and date is available before proceeding.

Support Staff Charges = FREE

• Charges for church support staff to open and close the building, media operators, and facility directors are waived due to these roles being filled by our Bereavement Team as a ministry to the family of the deceased.
• If you would like to, you are welcome to give a small monetary gift as a token of your appreciation to any of the support team.

Usage Charge = $400

• This covers the usage of the church including the Sanctuary or alternate room for the service.
• Charges for church support staff to open and close the building, media operators, and facility directors are waived due to these roles being filled by our Bereavement Team as a ministry to the family of the deceased.
• If you would like to, you are welcome to give a small monetary gift as a token of your appreciation to any of the support team.
• Cleaning – You are to leave the building as you found it.

Request For Use of Church Facilities

• Request may be made in the church office by filling out the request form. 
• Request may be made by church members or by others who are not members of this church.
• It is expected that any who accept use of the facilities also accept the church’s rules regarding funerals and memorial services.

Ministers

• Any ordained minister on the staff of Hickory Withe Baptist Church may be requested to do the service.
• If desired, the ceremony may be performed by an ordained minister who is not a member of the Hickory Withe Baptist Church staff, but this must be approved by the leadership of Hickory Withe Baptist Church.

Facilities

• Sanctuary – Flower arrangement deliveries, tables for pictures, and any other needs can be communicated through our Bereavement Team. Upon signing this summary, it is agreed upon to follow the instructions and assume the responsibility for any damage that may occur due to negligence.
• Facility Needs – The opening and closing of the church as well as any other specific needs concerning our facilities will be coordinated through our Bereavement Team.
• SMOKING OR ALCOHOLIC BEVERAGES ARE NOT PERMITTED ANYWHERE ON CHURCH PROPERTY.

Music

• The church retains the right to reject any music that does not coincide with our Mission Statement or principles from the Word of God.
• The audio/visual system and lighting system can only be operated by authorized Hickory Withe Baptist Church individuals and must be scheduled in advance with the Bereavement Team.

We agree to comply with the church policies regarding funerals and memorial services.

I, the undersigned, authorized representative(s) of {fullName} (Your Name or Organization) shall be using the building and grounds of First Baptist Church Hickory Withe Inc. (hereinafter “FBCHW”) from {visitationDate} to {serviceDate}, for the purpose of Funeral/Memorial Service herein referred to as “the activity”.

1.  I, the undersigned, represent that I am over the age of minority and have full authority to enter into this Church Usage And Waiver Of Liability And Hold Harmless Agreement (hereinafter “Agreement”).
2. I, the undersigned, represent that I will inform all members/participants of the group/organization on whose behalf I am using FBCHW for the activity, of the terms and conditions of this Agreement, and that any person that enters the premises of FBCHW and/or participates in the activity at FBCHW thereby agrees to the terms and conditions of this Agreement.
3. For consideration given and received in connection with the use of FBCHW for the activity, I hereby release, waive, discharge and covenant not to sue FBCHW, its trustees, representatives, employees, servants, officers, or agents (hereinafter referred to as “releasees”) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury, including death, that may be sustained by me, or members of my group/organization and guests, invited or not, or to any property belonging to me or my group/organization, whether caused by the negligence of the releasees, or otherwise, while participating in the activity, or while in, on or upon the premises where the activity is being conducted, or in any place or places connected with the activity.
4. As part of the consideration for being allowed to use FBCHW, its building and grounds, as well as all appliances and fixtures in the activity, I hereby assume all risk in connection with participation in the activity.  I am fully aware of risks and hazards connected with being on the premises of FBCHW and participating in the activity, and fully aware that there may be risks and hazards unknown to me connected with being on the premises of FBCHW and participating in the activity, and I hereby elect to voluntarily participate in the activity, to enter upon the premises of FBCHW and engage in activities knowing that conditions may be hazardous, or may become hazardous or dangerous to me and my person, property, and the persons and property of my organization.  I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me and/or my organization, or any loss or damage to property owned by me and/or my organization, as a result of using FBCHW for the activity or being on the premises of FBCHW for the activity, whether caused by the negligence of releasees or otherwise.
5. I further hereby agree to indemnify and save and hold harmless the releasees, separately and severally, from any loss, liability, damage or costs they may incur due to me and my organization’s use of FBCHW for the activity or being on the premises of FBCHW for the activity, whether caused by the negligence of any or all of the releasees, or otherwise.
6. I further agree to save and hold harmless FBCHW and the releasees from any claim by the undersigned, the undersigned’s employer/group/organization, estates, heirs, or assigns arising out of use of FBCHW and/or participation in any form or fashion in the activity.  It is my express intent that this Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above named releasees.
7. I also authorize FBCHW, its employees, or agents to render or obtain such emergency medical care or treatment as may be necessary should any injury, harm, or accident occur while participating in the activity.

In signing this release, I acknowledge and represent that:

1. I am authorized to sign this Agreement;
2. I have read the foregoing Agreement, understand it, and sign it voluntarily as my own free act and deed;
3. I understand the terms of this Agreement are contractual and not mere recitals;
4. No oral representation, statements or inducements, apart from the foregoing written Agreement, have been made;
5. I further state and acknowledge that I am fully informed of the content of this Agreement, have read it before signing it, and have had the opportunity to have it reviewed by others, including legal counsel of my choosing;
6. I execute this Agreement for full, adequate and complete consideration fully intending to be bound by same.

 

In witness whereof, I have hereunto set my hand and seal this day of {date}.

First Baptist Church Hickory Withe Inc. has adopted a resolution aimed at eliminating any potential for child sexual abuse in the church. The purpose for establishing a Child Abuse Prevention Policy is to demonstrate our total and unwavering commitment to the physical, emotional and spiritual safety of all the children and youth God has entrusted to our care.  This policy extends to all activities conducted on the church property or which, in any way, have an association, either formal or inferred, with FBCHW.

If the activities being conducted will be involve children and/or youth, the activity must comply with the following requirements:

There shall be a minimum of two (2) adults per room in any room containing children and/or youth.
These two adults must not be from the same immediate family.
Any one-to-one mentoring or consulting shall be conducted in sight of another adult.
Adult is defined as a person over the age of 21.
Adults involved in the activity must have been screened by either the organization conducting the activity or through FBCHW’s normal screening process. 
Organizations requesting use of the FBCHW grounds and/or facilities may either certify that the above requirements have or will be met.  If an organization cannot certify that compliant screening has been accomplished for at least 2 adults per room, that organization may request that FBCHW accomplish this screening for a fee of $25.00 per person.  Each person to be screened by FBCHW must complete a CRIMINAL HISTORY INFORMATION RELEASE FORM, which may be obtained from the church website at http://www.fbchw.org 

CERTIFICATION OF COMPLIANCE WITH CHILD ABUSE PREVENTION POLICY

I/We the undersigned authorized representative(s) of {fullName} (Your Name or Organization) do hereby certify that our organization understands and will comply with the two-adult provisions of the Child Abuse Prevention Policy of FBCHW.  I/We further certify that two adults per room have been screened in a manner compliant with this policy defined above.

I have executed this certification on the day of {date}.