2023-2024 Carmel Baptist Church Release & Consent Agreement for Youth Valid September 1, 2023

We, the undersigned participant and parent and/or legal guardian, for ourselves, our heirs, executors and administrators, HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE any and all claims for damages which the participant may have or which may hereafter accrue to the participant against CARMEL BAPTIST CHURCH, its members, officers, agents, representatives, successors and/or assigns, individually and collectively, for any and all loss, injury or damage which may be sustained and suffered by the participant in connection with his/her association with CARMEL BAPTIST CHURCH or arising out of traveling with, participating in or returning from any activity sponsored by CARMEL BAPTIST CHURCH (the “Church Activity”

We do hereby authorize any of the designated adults monitoring the Church Activity on behalf of CARMEL BAPTIST CHURCH to contact a physician for the participant and/or to dispense over-the-counter medications to the participant, if necessary. We also authorize such designated adults to consent to medical care necessary for the participant’s well-being, including x-ray examination, anesthetic, medical or surgical procedures or treatments and/or hospital care as advised by the participant’s physician and/or surgeons in the event that a parent/legal guardian or emergency contact cannot be reached. We further authorize such designated adults to share the Medical History Form attached to this Release and Consent Agreement with CARMEL BAPTIST CHURCH employees, agents and members, as necessary, and to medical personnel for purposes of treating the participant.

We hereby grant Carmel Baptist Church the absolute right and unrestricted permission to take photographs and/or video of the participant during a Church Activity and to use and distribute such photographs and/or video for purposes of marketing, publicizing activities of the church or for any other lawful purpose. Photographs or video of the participant may be used in printed publications, multimedia presentations, on websites or in any other distribution media.

We hereby grant Carmel Baptist Church and its ministry leadership to contact my student as it relates to the purposes of the ministry.

WE HAVE READ AND VOLUNTARILY SIGNED THIS RELEASE AND CONSENT AGREEMENT AND FULLY UNDERSTAND THAT WE HAVE KNOWINGLY GIVEN UP LEGAL RIGHTS BY VOLUNTARILY SIGNING IT.

*Participants SS

*Your child's social security number is OPTIONAL. If your child has to go to the hospital, the hospital will bill your insurance company if you have their social security number; if you don't have the social security number the hospital will bill you and you will submit the bill to your insurance company.

Participant Name*

First NameMiddle Name (opt)Last Name

Address (Street, City, State, Zip)*

Parent Phone*

Student Phone

In the event parents cannot be reached, please contact*

Relationship to participant*

Phone # of person named above*

Insured Person's Name*

Insurance Company*

Policy Number*

Name of Physician*

Participant's Signature*

Parent/Guardian Name*

First NameLast Name

Signature of Parent or Guardian*

Continue to next page for Student Health & Medical Form info.

Carmel Baptist Church Release & Consent Agreement Valid September 1, 2023 — August 30, 2024

Student Health and Medical Forms

Medical History – Medication Allergies

Medical History - Allergy History

Medical History - Medications

Medical History - Health History