IBC Parent Release for Children's Participation Form

IBC Parent Release & Student Participation Form
I/We the undersigned, parent(s) or legal guardian(s) of the minor listed below do authorize any X-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any state licensed physician or dentist and hospital service that may be rendered to said minor under the general, specific, or special consent of (IBC Pastor/Youth Minister) and /or authorized IBC sponsor, the temporary custodian of the minor. I/We further acknowledge that any activity carries risk of incident or accident resulting in injury or possible fatality and do hereby release liability of risk of incident or accident resulting in injury or possible fatality and do hereby release liability of Immanuel Baptist Church, Paris, Texas, its staff, and/or sponsor in case of such an occurrence. This consent shall remain effective until 12:00 midnight on the 31st day of May, 2025 unless sooner revoked in writing and delivered to (IBC Pastor/Children's Director) of Immanuel Baptist Church, Paris, Texas. Signatures of all parent/legal guardians are required on this form. I/We acknowledge that it is assumed by IBC that all parents and/or legal guardians of the stated minor have signed this form and acknowledge sole responsibility for release.

I/We also acknowledge and give consent for the minor listed below, of whom I/we hold legal custody, to participate in IBC activities in which the following conditions may exist (Consent is acknowledged by parent(s) and/or legal guardian(s) initialing next to each condition).

I/We acknowledge that my/our child may be riding in an automobile driven by only one approved adult and no fewer than two minors; never is there to be one adult and one minor left one on one in vehicle.

I/We acknowledge and approve of my/our child being counseled in the church office, one on one, by an approved minister of IBC, Paris, Texas.

I/We acknowledge and approve of my/our child participating in overnight church activities.

I/We acknowledge that the likeness of my child may be taken in photo or video format for advertising or promotional purposes. I release all claims on such media to Immanuel Baptist Church, Paris, Texas.
Signature*

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CHILDREN'S COVENANT

By signing this covenant, I agree to follow these guidelines during each of the IBC children's meetings and events so that I may be an example to others and fulfill the mission of IBC.

I promise to…

-Respect the leadership of the adult youth/children workers and volunteers.

-Be where I am supposed to be when I am supposed to be there doing what I am supposed to be doing.

-Respect my body, health, and the health of others.

-Respect others and their property.

-Use positive appropriate language that builds others up. For example:

-No gossip

-No peer pressure

-No making fun of others

-No vulgar language

-Wear clothing that is modest and does not make others uncomfortable.

-No PDA (Public Display of Affection).

-Represent my family and my church well.

I agree to follow this IBC Children's Covenant which is also the Code of Behavior for all persons that participate in the IBC Children's events. I understand that if I violate any of these rules, I will be counseled by the youth/children’s leader in the presence of another adult youth/children’s worker. If the violation is serious, the youth/children’s leader has the option of calling my parent/guardian and/or sending me home at my parent/guardian’s expense.
Student Name*

First NameLast Name
Student Signature*

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Parent Name*

First NameLast Name
Parent Signature*

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Student Information
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Name*

First NameLast Name
Parent Phone Number*
Please enter a valid phone number.
Parent Email*
example@example.com
Allergies and/or Complications*
List any medications taken on a regular basis*
Please list any allergies or other complications, conditions, and concerns*
Emergency Contact #1 (other than parent)*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Emergency Contact #2 (other than parent)*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Medical Insurance Co*
Policy #*
Family Doctor*
Hospital Preference*
Date of Last Tetanus Shot*
Upload Copy of Insurance Card*

Cancelof
This form is effective through June 1, 2026 or unless retracted by you or another authorized parent/gaurdian.

Child's Interests
Shirt Size*
Children's Sizes
School*
Sport (to watch)
Snack
Movie
Dessert
Sonic Drink
Candy Bar
Super Hero
Should be Empty:

IBC Parent Release & Student Participation Form

Student Information

Child's Interests