Release Waiver & Emergency Contact Form 2024

Release Waiver & Emergency Contact Form 2024

Imprint Student Ministries
Name of the Student*

First NameLast Name
MaleFemale
Birth Date*

MonthDayYear
Student Information
Student Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Student Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
YesNo
Please Explain Below:
Emergency Contact Information
Emergency Contact 1*

First NameLast Name
Relationship*
Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2*

First NameLast Name
Relationship*
Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Medical Insurance Company*
Policy/Group Number*
Does Your Student Have Any Allergies? *
Please List Allergies Below:
Does Your Student Take Any Medications?*
Please List Medication(s) And Dosage(s) Below:
Does Your Student Have Any Medical Diagnosis a Medical Professional Would Need to be Aware of in Case of a Medical Emergency? *
Please Explain Below:
Picture and Video Release
For valuable consideration received, I hereby give Imprint Student Ministries and Shirley Hills Baptist Church the absoule and irrevocable right and permission, with the repects to photographs and video images that it has taken of my student or in which they may be included with others, to copyright the same in its own name or any other name that he may choose, to use, re-use, publish, and republish the same in whole or in part, individually or in conjuctions with other protograph, in any medium and for any purpose whatsoever, including (but not limited to) illustration, promotion, advertisting and trade, and to use the name of my student in connection therewith.
YesNo
Parent and Liabaility Release Statement

I understand that Shirley Hills Baptist Church and Imprint Student Ministries carries medical and hospitalization insurance coverage which, consistent with the exclusions, limitations and terms thereof, may provide benefits over and above any personal medical and hopitalization coverages available to my family. I understand that any personal medical and hospitalization insurance avaiable to my family will provide primary coverage and the ministry's medical and hospitalization coverage (subject to exclustions, limitations, and provisions in the ministry's policy) may provide secondary or excess coverage. I agree to apply first for benefits from the personal hospitalization and medical coverages available to my family, if any, before applying for benefits that may be available from the ministry's medical and hospitalization coverage.

I further understand that, in the event my child requires medical or dental treatement while engaged in the activity, resonable efforts will be made to contact the persons listed on the form; however, if I cannot be reached, I hereby consent and give my permission to the ministry's sponsor or any adult counselor acting on behalf of the ministry with respect to the activity, as agent for me, to consent to any X-ray examination, injections, anesthesia, medical, dental, or surgical diagnosis and treatment, and hospital care and treatment advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital.

To the best of my knowledge, I have listed above all of my child's medical allergies, medications being taken, medical diagnosis, and other pertinent information.

I understand all resonable safety precautions will be taken at all times by Shirley Hills Baptist Church and its agents during the events and activities in which my child participates. I understand the possibility of unforseen hazards and know the inherent possibility of risk. I agree to not hold Shirley Hills, its staff, leaders, employees, and volunteer staff liable for damages, losses, diseases, injuries, or accidental death incurred by the subject of this form. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the staff, leaders, employees, and volunteer staff of Shirley Hills Baptist Church.

I have read the above waiver and release and by signing it agree it is my intention to except and relieve Shirley Hills Baptist Church from liability for personal injury, property damage, or wrongful death caused by negligence or any other cause.
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Release Waiver & Emergency Contact Form 2024

Student Information

Emergency Contact Information

Medical Information

Picture and Video Release