SMC STUDENT PARTICIPATION FORM 2025-2026

SMC STUDENT PARTICIPATION FORM 2025-2026

PLEASE COMPLETE A SEPARATE FORM FOR EACH STUDENT REGISTERING.
Student's Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Student Email
example@example.com
Student Phone #

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Parent or Guardian Name*

First NameLast Name
Primary Contact's Email Address*
Primary Contact Phone Number*

Area CodePhone Number
Secondary Parent or Guardian Name

First NameLast Name
Secondary Contact's Email Address
Secondary Contact's Phone Number

Area CodePhone Number
Student's Grade in School*
How would you like to get involved this year?*

Sunday NightsWednesday NightsPumpkin PatchYouth TripsYouth SundaysAll of the Above
Tshirt size this Year*

Adult SAdult MAdult LAdult XLAdult XXLAdult XXXL
Please list below Insurance Carrier, Policy # and Telephone #*
Emergency Contact Name and Phone Number*
Please list all Allergies:*
Any special needs or concerns you would like to share regarding your student?
It is my understanding that Southside Methodist will attempt to notify me or a given emergency contact in case of an emergency with the above student. If the manager can not reach me or the designated emergency contact, then I authorize the coffee shop to hire a doctor or health-care professional, and I give permission to the doctor or other health-care professional, to provide the medical services he or she may deem necessary and pay for any medical expenses so incurred. Please sign below giving authorization to treat:*

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RELEASE and WAIVER OF LIABILITY By signing below, I assume all risks and hazards incidental or resulting from or otherwise arising out of or relating to my use or my minor child’s use, and/or participation in any activities sponsored by Southside Methodist or occurring on or about the properties or using any fixtures or equipment (collectively, the “Properties”) of Southside, including, without limitation, any mental, physical, emotional, bodily injuries or death caused by or resulting in any way from my participation or, my minor child’s participation, in any such activities sponsored by Southside, whether caused in any way by me, my minor child, or any other person or participant, or by the conditions of the Properties or from injury or damage of any nature whatsoever to persons or property resulting from being in the vicinity of the Properties. I understand that injuries may occur from participation in a coffee shop, whether or not caused by my acts, my minor child’s acts or the acts of other persons or the coffee shop. I fully understand the risks involved and acknowledge that I have had the opportunity to ask questions and further inquire about the same with Southside. I also represent that I have consulted with a physician to confirm that my (or my minor child’s) physical health, fitness and condition are appropriate for my (or my minor child’s) intended participation in working and uses of the equipment. Happy Brew may have made no representations or guarantees whatsoever that it carries accident or liability insurance which may cover my injuries, my minor child’s injuries or those of anyone else. I understand that this document involves legal consequences to me or my minor child and that by signing this document I am giving up valuable legal rights. I AGREE THAT PARTICIPATION IN SOUTHSIDE METHODIST ACTIVITIES AND THE USE OF THE PROPERTIES SHALL BE UNDERTAKEN AT MY SOLE RISK OR MY MINOR CHILD’S SOLE RISK AND THAT THE CHURCH SHALL NOT BE LIABLE TO ME FOR ANY INJURIES, DAMAGES TO PROPERTY OR PERSONS, ACCIDENTS OR DEATHS DIRECTLY OR INDIRECTLY ARISING OUT OF OR RELATING TO MY PARTICIPATION IN (OR MY MINOR CHILD’S PARTICIPATION IN) SOUTHSIDE METHODIST ACTIVITIES OR MY USE (OR MY MINOR CHILD’S USE) OF THE PROPERTIES. I DO HEREBY FOREVER, UNCONDITIONALLY AND EXPRESSLY RELEASE, DISCHARGE, WAIVE, RELINQUISH AND COVENANT NOT TO SUE HAPPY BREW OR ANY OF ITS EMPLOYEES, INCLUDING, BUT NOT LIMITED TO, THE DIRECTOR, MANAGERS, EMPLOYEES, AGENTS, VOLUNTEERS, MEMBERS OR PARTICIPANTS FOR ANY SUCH INJURIES, DAMAGES, INCIDENTS OR DEATHS EVEN IF CAUSED BY THE NEGLIGENCE OF THE CHURCH OR ITS OFFICERS, EMPLOYEES, DIRECTORS, MEMBERS OR AGENTS OR BY THE NEGLIGENCE OF OTHERS. I agree to defend, indemnify and hold harmless Southside Methodist and its employees, officers, members, directors and agents from and against every type of risk, loss, injury or damage, of whatever kind or nature, the coffee shop may incur as a result of my participation in (or my minor child’s participation in) coffee shop activities or the use (or my minor child’s use) of the Properties. In an emergency, if either myself, another of my family members or the family physician cannot be reached, I hereby authorize my treatment (or my minor child’s treatment) by another physician and that all reasonable and necessary medical procedures and measures be utilized. Please sign below that you have read and understand:*

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Photo Permission for Students:*

I give permission for still or video pictures of myself or my child to be used for promotional purposes.I do NOT give permission for still or video pictures of myself or my child to be used for promotional purposes.
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