Life Center Enrollment Form

Mt. Airy Baptist Church Life Center Enrollment Form and Release
Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number - Cell
Format: (000) 000-0000.
Phone number - Home
Phone number - Work
Email address
example@example.com
Please select status:
If you a member of another church, what church?
Family physician
Office phone
Format: (000) 000-0000.
Notify in case of emergency
Phone
Format: (000) 000-0000.
Mt. Airy Baptist Church Life Center Enrollment Form and Release

Special Medical Issues (please list any special medical issues or problems including allergies for each family member enrolled):
Name
Special medical issues
Name
Special medical issues
Name
Special medical issues
Name
Special medical issues
Name
Special medical issues
Name
Special medical issues

Other family members wishing to enroll:

RELEASE/PERMISSION CLAUSE
I. (We) the undersigned applicant, parent or guardian of applicant for participation in the Life Center programs of Mt. Airy Baptist Church ("MABC"), Easley, South Carolina, do hereby release and discharge MABC and its authorized representatives and staff (both paid and volunteer) from all liability of any kind and character upon any claim, demand, or cause of action which might be assessed against MABC, its representatives or staff. Furthermore, in the event of an accident, should the MABC staff or representative be unable to contact the parent(s) or guardian(s), I (we) hereby grant permission to said staff or representatives to administer necessary first aid, and/or to take applicant to the nearest medical facility for additional treatment.

I (We) have been offered a copy of the policies and procedures and will abide by all such policies and procedures. I (We) assume all risk and responsibility as I (we) participate in activities at the Life Center. Further, I (we) accept all equipment for use as is with all defects.I (we) will inspect any equipment and, if used, agree that it is in good repair.

Signature of Applicant(s) [MUST BE AT LEAST 18] or Signature of Parent(s) or Guardian(s), if not
Signature of Applicant (MUST BE AT LEAST 18 YEARS OLD)
or Signature of Parent(s) or Guardian(s), if not 18 years old
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: