Life Center Enrollment Form

Mt. Airy Baptist Church Life Center Enrollment Form and Release

Name*

First NameLast Name

Date of birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number - Cell *

Phone number - Home

Phone number - Work

Email address

example@example.com

Please select status:*

Mt. Airy memberMt. Airy visitorMember of another churchNot currently attending a church

If you a member of another church, what church?

Family physician*

Office phone

Notify in case of emergency*

Phone*

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:

	Name	Relation	Date of Birth	Gender	MABC Member?
1
2
3
4
5

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*

Date

RELEASE/PERMISSION CLAUSE