Student/Participant Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

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Birthday *

MM

DD

YYYY

Father

First Name

Last Name

Father's Work Phone

(###)

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Father's Cell Phone

(###)

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Mother

First Name

Last Name

Mother's Work Phone

(###)

###

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Mother's Cell Phone

(###)

###

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Guardian(s)

First Name

Last Name

Guardian Work Phone

(###)

###

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Guardian Cell Phone

(###)

###

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Emergency Contact (if parent/guardian cannot be reached) *

First Name

Last Name

Emergency Contact Primary Phone *

(###)

###

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Emergency Contact Secondary Phone

(###)

###

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Family Physician *

First Name

Last Name

Physician Phone Number *

(###)

###

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Family Dentist *

First Name

Last Name

Dentist Phone Number *

(###)

###

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Insurance Company Phone Number

(###)

###

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Name of Primary Insured

First Name

Last Name

Birth Date of Primary Insured

MM

DD

YYYY

I realize I must submit a copy of the front and back of participant's medical insurance card to info@elambaptist.org. *

Yes, I will submit a copy

Elam Baptist Gray (Together With Their Respective Officers, Employees and Agents) and Each Volunteer Assisting Them Are Collectively Designated By The Abbreviation "EBC" Throughout This Entire Form and the Term "EBC" Shall Refer to Them Individually As Well As Collectively. *

-I (we) hereby authorize "EBC" to take my (our) child for medical treatment in the event of an illness or injury in which neither parent can be reached after a reasonable attempt to do so. -I (we) do hereby authorize any physician, dentist, hospital or medical treatment center to treat my (our) child in the case of emergency. The undersigned adult shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume and be responsible for the payment of all transportation costs. -I (we) hereby authorize EBC to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care to be rendered to my (our) child under the general or special supervision and on the advice of any physician or dentist representing to be licensed on the medical staff of a hospital or medical care facility, whether such diagnosis or treatment is rendered at the office of said physician or at the said facility or hospital. -I (we) hereby do authorize EBC to dispense to my (our) child any over-the-counter medications (according to proper dosage instructions) when reasonably deemed necessary. -I (we) hereby give permission for my (our) child to attend and participate in activities sponsored by EBC. -I (we) hereby authorize EBC to transport my (our) child to or from church and/or any other church related and sponsored activities and events. -I (we) authorize EBC to include my (our) child in routinely supervised water activities. -I (we) hereby release, forever discharge and agree to defend and hold harmless EBC from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any , nature whatsoever which may be incurred by the undersigned adult and the child/participant that occur while said child is participating in any trip or activity with EBC. -I (we) (and on behalf of my (our) child) hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein. Further authorization and permission is hereby given to EBC to furnish any necessary transportation, food, and lodging for my (our) child. -The undersigned further hereby agrees to hold harmless and indemnify EBC from and against any claim against or loss incurred by EBC as the result of the negligent, willful, or intentional acts of my (our) child, including any expense incurred attendant thereto. -The medical consent and liability waiver provisions hereof shall remain in fuIl force and in effect until written notice of revocation or withdrawal is received by EBC at its office at 203 Elam Church Road Gray, Georgia 31032. -I (we) acknowledge and agree that it is my (our) responsibility to notify Elam Baptist Church of any changes in medical condition, guardianship, address or telephone, in writing to the address listed at the beginning of this form.

I (we) have read and agree to these terms and conditions.

Student Digital Signature *

First Name

Last Name

Student Signature Date *

MM

DD

YYYY

Legal Guardian Digital Signature *

First Name

Last Name

Legal Guardian Signature Date *

MM

DD

YYYY