Marion Avenue Bus Rider Registration.2

Route:

Registration filled out by- Parent/ Legal Guardian's Name:

First NameLast Name

Parent/ Legal Guardian's Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Parent/ Legal Guardian's Email

example@example.com

Rider's Name:

First NameLast Name

Grade:

Address:

Street Address

Apt or Trailer #

CityState

Zip Code

Food Allergies or Medical Conditions/Concerns:

Emergency Contact's Name:

First NameLast Name

Emergency Contact's Relationship to Rider:

Emergency Contact's Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

MEDICAL: If reasonable attempts to contact me have been unsuccessful, I hereby give permission to the Marion Avenue Baptist Church to secure necessary medical treatment including transport to a local hospital, and for any licensed physician or dentist to administer any treatment considered necessary. I accept that payments and billings of said emergency treatment and transportation will be my responsibility. INITIAL YOUR AGREEMENT BELOW

MEDIA/PHOTOGRAPHY: I acknowledge the use of media, such as the live-streaming of services and videography/ photography of events, by the Marion Avenue Baptist Church. I acknowledge and approve that my child may appear in media that appears online or in promotional materials in connection with the Marion Avenue Baptist Church. INITIAL YOUR AGREEMENT BELOW

CONSENT & LIABILITY: As the parent or legal guardian, I hereby authorize and grant permission for the above named rider to be enrolled in and participate in the Marion Avenue Baptist Church's Bus Program. I hereby voluntarily release, discharge, and relinquish any and all actions, causes of actions, and claims for personal injury or insult or any property damage of or to the participants; arising out of, or in any way related to, their participation in the Marion Avenue Baptist Church's Bus Program. I understand that this release is intended to, and does discharge in advance the Marion Avenue Baptist Church and any and all of its officers, volunteers, and employees from any and all liability, actions, and causes of actions. I understand that the Marion Avenue Baptist Church is not responsible for the actions or words of other participants and thus can not be held legally responsible for any of their actions and causes of actions. I have carefully read and fully understand this agreement. My signature shows my agreement and acceptance of this legally binding agreement and I sign it of my own free act. FULL SIGNATURE BELOW

Relationship to Rider:

Date of Registration Completion:

Date