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Youth & Family Ministry Release & Payment

- Youth & Family

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- Parent Name REQUIRED Please fill out this field. Please enter valid data.
- Are you interested in volunteering in one of our programs? REQUIRED Please fill out this field.
- Comments
- Number of Children Registering REQUIRED Please fill out this field.
- Please list Names of all Children registered REQUIRED Please fill out this field.
- Medical & Liability Release Statement
  
  I understand that in the event of any injury or illness, every attempt will be made to contact the persons listed on this registration form. In the event I cannot be reached in an emergency, I hereby authorize and consent to the transportation of Participant to the nearest medical or dental facility, and, should the need arise, I hereby further authorize and consent to any x-ray, examination, anesthetic, medical or surgical diagnosis and treatment in the discretion of the attending physician or dentist. I understand that I am giving this authorization in advance of any specific diagnosis, treatment or hospital care being required and I am providing this authorization to give authority and power to render any care which the medical provider and/or dental provider deems advisable. None of the foregoing medical or dental treatments shall be withheld if I cannot be reached prior to the administration of such medical and/or dental treatments. I hereby agree that I shall be solely responsible for the payment of any and all costs for such medical and/or dental treatment of Participant, and in no event shall any of the Church Parties be required to pay for any such costs or expenses. I, INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT, HEREBY, RELEASE, WAIVE, AND FOREVER DISCHARGE THE CHURCH PARTIES FROM ANY AND ALL LIABILITY, CLAIMS, LOSSES, JUDGMENTS, DAMAGES, COSTS, EXPENSES, AND DEMANDS OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR IN EQUITY, RESULTING OR ARISING FROM ANY SUCH MEDICAL OR DENTAL TREATMENT RENDERED TO PARTICIPANT.
  
  I Agree To the Above Medical & Liability Release Statement Please select this field.
  
  Date REQUIRED Please fill out this field. Please enter a date.
- Promotional Advertisement and Media Release
  
  Permission for my child's name and/or photograph to be used as in the capacity of Youth & Family Ministry advertising and/or media releases REQUIRED Yes, I give my permission to use my child's name or photograph No, I do not give my permission for my child's name to be used or photographed Please fill out this field.
  
  Date REQUIRED Please fill out this field. Please enter a date.
- Flocknote
  
  By supplying your cell phone and email, you will automatically be registered for Flocknote - our email/text mass communication system. We use Flocknote to quickly inform you of important information.
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