Concord Students Nonpayment Form

Concord Students Non-Payment Form

You may use this fund to register as a non-paying participant to an event or to request a scholarship.
Student Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Student Cell*
Current Grade*
Gender*
What event are you requesting a scholarship for?*

Big WeekendWild WeekBeach Week
Are you requesting a scholarship?

YesNo
At First Concord, we don't want a lack of funds to keep you from attending one of our events. We give out a limited number of scholarships for our events. Most of these scholarships are for half of the cost of the event. So that we may be good stewards of our limited scholarship funds that are donated, please answer the following questions to the best of your ability.
Amount of scholarship requested:
Please tell us why you need this scholarship:
Parent's names:*
Parent's email:*
Parent's phone number*
Who is one person you would like to stay with?*
Any allergies?

Waiver
I, as the parent or guardian of the student in this registration and by this instrument, I do hereby release, acquit, hold harmless and forever discharge FIRST BAPTIST CHURCH CONCORD, its agents, servants, and employees, and all persons, natural or corporate, in privity with them or any of them, from any and all claims or causes of action of any kind whatsoever, including but not limited to actions, suits and/or claims for any bodily injuries, death or property damage which may be sustained by my child while participating in any activity, or activities, including travel to and from such activities and any negligence or lack of care due or claimed to be due to the conduct of any agent, servant, or employee of FIRST BAPTIST CHURCH CONCORD. By signing this agreement, I give my permission for my child to receive medical attention in the event of an emergency. It is my responsibility to provide current and correct insurance information to the Student Ministry offices and my responsibility to update such information should it change within the year. I understand and will allow photos and videos of my child to be taken while at FIRST BAPTIST CHURCH CONCORD to be used in any FIRST BAPTIST CHURCH CONCORD publication. I also understand that publication of these photographs may be accomplished electronically via the Internet and that after publication, the church will be unable to prevent persons from gaining access to the Internet, copying my photographs and video from there, and subsequently using, altering, or republishing them without my consent. I waive any claim for damages against the church from unconsented use, alteration, or republishing of my photographs and video by third parties accessing the Internet. I certify that I have read this document, and I fully understand it’s contents/ I am aware that this is a release of liability and a contract and I sign it of my own free will. TYPE SIGNATURE OF PARENT OR GUARDIAN:*

First NameLast Name
I understand this counts as an electronic signature:*

Yes
Name of Insurance Company*
Policy Number*
Should be Empty:

Concord Students Non-Payment Form

Waiver