Child's First Name
Child's Last Name
Birthdate
Last Grade Completed
Parent/Guardian Name
Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Parent Email Address
LIABILITY RELEASE: In consideration of Austell First United Methodist Church (AFUMC) allowing the above child(ren) to participate in Vacation Bible School activities, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless AFUMC, its directors, employees, volunteers, and agents (collectively herein the “Church”) from any and all liability, claims, or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever that may be incurred by the undersigned and the above child(ren) while involved in Vacation Bible School. Furthermore, on behalf of my minor child(ren), I hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in activities involved therein. As well as releasing the child(ren), if necessary, for transportation to and from the Vacation Bible School location, I, the undersigned, do hereby release, forever discharge, and agree to hold harmless AFUMC, its directors, employees, volunteers, and agents from any and all liability, claims, or demands for accidental personal injury in the process of transportation.
MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed on the medical staff of a licensed hospital or emergency care facility. The undersigned 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(ren) pursuant to this authorization.
PHOTO/VIDEO PERMISSION: I DO / DO NOT (circle one) give my consent to AFUMC to use photo or video images taken of my child(ren) in church brochures, advertisements for the church, on the website, in social media, and in other church publications as they see fit. I agree to hold harmless AFUMC from any liability which may result from the use of said picture(s). This form will apply throughout my child(ren)’s tenure at AFUMC’s Vacation Bible School. **None of the photos will be for personal use.**
I hereby give permission for my child(ren) to participate in Vacation Bible School at AFUMC on Date/Time
Time
Parent /Guardian Signature
Complete the following for each child in the family.
Child's Name
Insurance Company
Policy/Group ID#
Allergies, Medications, and/or Medical Conditions
Activity Restrictions
Parent/Guardian Phone Number(s)
Emergency Contact: person(s) & phone numbers in case parent/guardian cannot be reached:
Name(s)
Contact Phone
People authorized to pick up my child
Register
