CHILD EMERGENCY & MEDICAL INFORMATION FORM

CHILD EMERGENCY & MEDICAL INFORMATION FORM

FAMILY CHURCH PC, FLORIDA
Name

First NameMiddle NameLast Name
Age
Grade
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Cell Phone
Parent/Guardian Name

First NameLast Name
Cell Phone
List any allergies your child has:
List any medical issues and/or medications your child has:
In case of emergency and the parent/legal guardian cannot be reached, contact the following:
Name
Relationship
Phone
Name
Relationship
Relationship
In the absence of the parent/legal guardian, the following person is authorized to pick up the above named
Name
Relationship
Phone
Name
Relationship
Phone
Signature of Parent/Legal Guardian
Date

MonthDayYear
Date
4854-8219-5427, v. 2

In consideration for accepting my child, First Name Last Name, for participation in Type a label I do hereby release, forever discharge and agree to hold harmless First Baptist Church of Port Charlotte, Florida and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above described trip or activity including recreation and work activities. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees and agents for any liability
Signature
Date

MonthDayYear
Date
Signature
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Parent/Guardian Consent Form

For Photo/Video/Internet
Child' Name

First NameMiddle NameLast Name
Permission to photograph/Video Tape (check one)
I give my permission to allow my child to be photographed or videotaped for use in promotional materials, official publications, displays and video productions that relate to First Baptist Church of Port Charlotte. I acknowledge the Church’s right to crop or treat the photographs or digital media at its discretion. My consent applies only to the use of such materials for non-profit, non-commercial purposes.
Internet Permission (check one)
I give my permission to allow my child to be photographed or videotaped for use in promotional materials, official publications, displays and video productions that relate to First Baptist Church of Port Charlotte and are displayed on the internet. I acknowledge the Church’s right to crop or treat the photographs or digital media at its discretion. My consent applies only to the use of such materials for non-profit, non-commercial purposes.
Parent/Guardian Name:
Signature
Date

MonthDayYear
Date
4854-8219-5427, v. 2

Release and Waiver of Liability
This Release and Waiver of Liability (the “Release”) executed on this Numerical Day* day of Month*, 20 Year , by First Name* Last Name* (the “Guardian”), the parent or legal guardian ofFirst Name* Last Name* (the “Minor”), in favor of the FIRST BAPTIST CHURCH OF PORT CHARLOTTE, INC. d/b/a Family Church and its directors, officers, employees and agents (the “Released Parties”).
In consideration of permitting the Minor to observe, or use any facility or equipment of the Released Parties, or engage in and/or receive instruction in any activity conducted on the property of the Released Parties (the “Activities”), SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY, the Guardian , individually and on behalf of the Minor, will and does hereby release, indemnify and hold harmless the Released Parties from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, that arise or may hereafter arise from the Minor’s participation in the Activities.

The Guardian, on behalf of the Minor, hereby freely, voluntarily and without duress executes this Release under the following terms:

1.      Activities. This Release is given by an on behalf of the Minor by the Minor’s Natural Guardian in order to induce the Released Parties to permit the Minor to participate in the Activity. The purpose of this Release is to waive and release, in advance, any claim or cause of action that Minor and/or Guardian may incur in connection with the Activity and all activities undertaken in connection therewith, including claims arising from the Inherent Risks of the Activity.

2.      Inherent Risk. As used herein the term “Inherent Risk” means those dangers or conditions, known or unknown, which are characteristic of, intrinsic to, or an integral part of the Activities and which are not eliminated even if Released Parties act with due care in a reasonably prudent manner. Such Inherent Risks include but are not limited to the risk of injury, the risk that the Minor or another participant in the Activities may act in a negligent or intentional manner and contribute to the injury or the death of the Minor and the failure of the Released Parties to warn the Minor or Guardian of any inherent risks.

3.      Release and Waiver. Guardian hereby individually and on behalf of the Minor hereby expressly waives and releases any and all claims, now known or hereafter known, against the Released Parties, and their respective officers, directors, manager(s), employees, agents, affiliates, members, successors, and assigns on account of injury, disability, death, or property damage arising out of or attributable to my participation in the Activities, whether arising out of the ordinary or gross negligence of the Released Parties or any of them or otherwise. Guardian individually and on behalf of the Minor hereby covenants not to make or bring any such claim against any Released Party, and forever releases and discharges the Released Parties of and from any and all liability under, for or in connection with such claims.

4.      Indemnification. Guardian, Individually and on behalf of the Minor shall defend, indemnify, and hold harmless the Released Parties, against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including attorney fees, fees and the costs of enforcing any right to indemnification hereunder, arising out of or resulting from any claim of a third party related to participation in the Activities, including any claim related to the negligence or gross negligence of the Minor or any Released Party.

5.      Assumption of the Risk. Guardian further, individually and on behalf of the Minor, acknowledges that the Activities may involve serious risks which could result in physical or emotional injury, paralysis, disability, or death to the Minor or to third parties, as well as property damage. Some of the risks arise from: (1) the Inherent Risks of the Activity; (2) latent or apparent defects in or the condition of equipment or property; (3) use of property or equipment by the Minor or others; (4) the Minor’s own acts or omissions as well as the acts or omissions of other participants in the Activities; (5) acts or omissions of the Released Parties; (6) the Minor’s physical condition or the physical condition of others; (7) weather and other natural conditions; and (8) first aid, emergency medical treatment or emergency transportation. Guardian both individually and on behalf of the Minor hereby, freely and voluntarily accepts and assumes all risks associated with the Activity, including but not limited to those risks generally identified herein.

6.      Insurance. The Guardian understands that, except as otherwise agreed to by the Released Parties in writing, the Released Parties do not carry or maintain health, medical or disability insurance coverage for any minor.

7.      Medical Attention. Guardian hereby consents to the medical treatment to the Minor as deemed necessary if the Minor is injured or requires medical attention during participation in any of the Activities. Guardian understands and agrees that Guardian will be solely responsible for all costs related to such medical treatment and any related medical transportation and/or evacuation. Guardian hereby releases, forever discharges and holds all of the Released Parties harmless of and from any and all claims based on such treatment or other medical services.

8.      Other. Guardian expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Florida and that this Release shall be governed by and interpreted in accordance with the laws of the State of Florida. Guardian also agrees that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable. This Release shall cover all subsequent Activities and events involving the Released Parties in which the Minor participates. Any claim or cause of action arising under this Release may be brought only in the federal and state courts located in Charlotte County, Florida and Guardian, individually and on behalf of the Minor, hereby consents to the exclusive jurisdiction of such courts.
4854-8219-5427, v. 2

NATURAL GUARDIAN

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITIES. YOU ARE AGREEING THAT, EVEN IF FIRST BAPTIST CHURCH OF PORT CHARLOTTE, INC. D/B/A FAMILY CHURCH OR THE OTHER RELEASED PARTIES USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THE ACTIVITIES BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITIES WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM THE RELEASED PARTIES IDENTIFIED ABOVE IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITIES. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND SPONSOR HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
4854-8219-5427, v. 2

By signing below the undersigned warrants and represents that he/she is the Natural Guardian of the Minor identified herein as defined in Fla. Stat. §744.301, that he/she has full authority to execute this Release and Waiver of Liability on behalf of the Minor without the consent of any other party, and that the parental, guardianship or other rights of the undersigned to give this Release on behalf of the Minor have not been terminated, limited or otherwise modified.

IN WITNESS WHEREOF, Guardian has executed this Release as of the day and year first above written.
Guardian's Signature:
Guardian's Full Name:

First NameLast Name
Date:

MonthDayYear
Date
Full Name of Minor:

First NameLast Name
4854-8219-5427, v. 2
Should be Empty:

CHILD EMERGENCY & MEDICAL INFORMATION FORM

Parent/Guardian Consent Form

Release and Waiver of Liability