WINNSBORO FIRST BAPTIST CHURCH STUDENT MINISTRIES

PARENT PERMISSION AND MEDICAL RELEASE FORM

DISCIPLE NOW WEEKEND – FEBRUARY 25-27, 2011-WINNSBORO FIRST BAPTIST CHURCH

NAME ______________________________________________________________________ AGE ___________

ADDRESS __________________________________________________________________________________

__________________________________________________________________________ ZIP ____________

PARENTS’ NAME __________________________________________________ PHONE # ____________________

I (WE) GIVE OUR APPROVAL FOR _______________________________________ TO ATTEND

THE WINNSBORO FIRST BAPTIST CHURCH DISCIPLE NOW WEEKEND, FEBRUARY 25-27. WE ASSUME ALL
RISKS AND HAZARDS INCIDENTAL TO THE CONDUCT OF THE ACTIVITIES AND TRANSPORTATION
TO AND FORM THE AREA. WE DO HEREBY RELEASE, ABSOLVE, INDEMNIFY AND HOLD HARMLESS
WINNSBORO FIRST BAPTIST CHURCH, THE ORGANIZERS, SPONSORS, AND SUPERVISORS FROM
ANY AND ALL LOSS, INJURY, OR OTHER DAMAGE TO US OR THE ABOVE NAMED PARTICIPANT
ARISING OUT OF THE EVENT. IN CASE OF INJURY TO THE ABOVE NAMED PARTICIPANT, WE
HEREBY WAIVE ALL CLAIMS AGAINST THE CHURCH, THE SPONSORS, OR ANY OF THE
SUPERVISORS APPOINTED BY THEM. WE LIKEWISE RELEASE FROM RESPONSIBILITY ANY PERSON
TRANSPORTING THE ABOVE NAMED PARTICIPANT TO AND FROM THE EVENT AND ITS ACTIVITIES.

DATE_________________PARENT SIGNATURE _______________________________________________

TO THE ATTENDING PHYSICIAN OR HOSPITAL:

PERMISSION IS HEREBY GRANTED FOR YOU AT THE DISCRETION OF Fran Shepard OR Nancy
Jolly TO PERFORM WHATEVER CARE IS NECESSARY FOR THE WELFARE OF _____________________
UNTIL SUCH TIME AS YOU ARE ABLE TO REACH US PERSONALLY.

DATE_________________ PARENT SIGNATURE _______________________________________________

PERSONS TO CONTACT IN CASE OF EMERGENCY:

PARENTS ____________________________________ PHONE # __________________________________
____________________________________ PHONE # __________________________________
MOBILE # ______________________________________
OTHER _____________________________________ PHONE # ___________________________________
LIST ANY KNOWN ALLERGIES OR MEDICAL PROBLEMS THE ABOVE NAMED PARTICIPANT MAY
HAVE: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
HOSPITALIZATION INSURANCE COMPANY __________________________________________________
POLICY # ________________________________ NAME INSURED ________________________________