VBS 2022 - Bethel UCC

1
Child #1 Name and Date of Birth* This field is required.
Child's Full Name
Date of Birth (mm/dd/yyyy)
2
Child #2 Name and Date of BirthIf none, select NEXT
Child's Full Name
Date of Birth (mm/dd/yyyy)
3
Parent/Guardian Contact Information* This field is required.
Full Name
Address
Phone #
Email Address
4
Emergency Contact InformationPlease list any other people you would like contacted in the event staff are unable to make contact with the primary parent/guardian listed above
Full Name
Relationship to Child
Emergency Contact Phone #
5
Physician's Name and Office Phone #
Physician's Name
Phone #
6
Who has permission to pick up your child?* This field is required.Please list all of the individuals that will have your permission to pick up your child(ren) from this event.
7
Would You Like To Sign Our Liability Waiver Online, or Print & Sign?
Sign Online
Print & Sign
8
I have printed out and signed this form and will submit it to a Bethel UCC staff member:* This field is required.If you have changed your mind and would like to sign this document online, please select the "Previous" button below and then select "Sign Online."
Yes
9
I (We) the Parent(s)/Guardian(s) give permission for my(our) above-named Child to engage in the Planned Activities which may be sponsored in whole or in part by Bethel United Church of Christ (Church) for the Inclusive Dates.* This field is required.
I have read and understood this section
10
I (We) understand that there are numerous risks associated with participation in any youth indoor/outdoor, athletic, and social activity including bodily harm, injury, or property damage. I (we) further understand that such injury or damage may be caused by intentional or unintentional acts or events arising from circumstances or individuals over which the Church has only limited control or no control whatsoever.* This field is required.
I have read and understood this section
11
In consideration for the privilege of allowing my (our) Child to participate in the Planned Activities, I (we), and on behalf of my (our)Child, our heirs, estate, executor, administrator, and assignees, agree to release, hold harmless, defend and indemnify the Church, its trustees, officers, directors, agents, representatives, employees and volunteers, from and against any and all losses, damages, demands, liability or responsibility for bodily injury, damage or illness to my (our) Child arising out of his or her participation in any youth indoor/outdoor, athletic or social activity which may be directly or indirectly sponsored by the Church. Further, I (we), and on behalf of my (our) Child, our heirs, estate, executor, administrator, and assignees, agree to indemnify, release and hold harmless the Church, its trustees, officers, directors, agents, representatives, employees or volunteers, from and against any and all claims, costs, expenses, liabilities, losses, damages, injunctions, suits, actions, fines, penalties, demands or causes of action of every kind or nature whatsoever asserted by, or on behalf of, my (our) Child in connection with bodily injury, illness, or damage as a result of my (our)Child participating in any youth indoor/outdoor, athletic or social activity which may be directly or indirectly sponsored by the Church. This release and waiver also covers dispensing medication as I authorize below.* This field is required.
I have read and understood this section
12
Should my (our) Child require immediate or emergency medical care while engaged in an activity sponsored by the Church, in my(our) absence, I (we) hereby grant the Church authority to release my (our) Child for medical treatment to such medical personnel as the Church determines appropriate under the circumstances.* This field is required.
I have read and understood this section
13
In the event that my (our) child becomes ill with symptoms such as headache, vomiting, sore throat, fever, or diarrhea, do you grant permission for supervisors to give your child non-prescription medication, such as acetaminophen, throat lozenges, cough syrup, or antacid?* This field is required.
I have read and understood this section
14
My (our) Child has the following medical conditions, allergies or impairments which may be material to participation in the Planned Activities:* This field is required.
15
My (our) Child currently takes the following medications, prescription and over-the-counter, at home and during the school day(Include all as-needed and emergency medications):* This field is required.
16
I (we) understand that with respect to any injury or illness that may occur in the course of the Planned Activities, I am (we are) solely responsible for making health insurance coverage available to my (our) Child. I (we) agree to provide sufficient health insurance coverage for my (our) Child and will rely on it exclusively to address any injury or illness that he or she may incur. READ CAREFULLY. THIS PERMISSION IS A LEGAL DOCUMENT WHICH PROVIDES A RELEASE OF LIABILITY AND INDEMNIFICATION. By signing below, I (we) represent that I am (we are) fully aware of and understand the terms and legal consequences of signing this Waiver and Release. I (we) intend this waiver and release to be a complete and unconditional release of all liability to the greatest extent allowed by law.* This field is required.
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