FELLOWSHIP BIBLE CHURCH >> CHILD SIGNUP FORM

RELEVANT - Fast Food Frenzy Night - Wednesday, January 6th, 2016

Child Informa/on
Child First Name: ___________________________

Child Last Name: ________________________________

Gender: M F
Grade: ____
Age: ____
Birthdate: __ / __ / ____
Address: ____________________________________ City: ______________________ State: ___ Zip: ___________
Allergies: ________________________________________________________________________________
Medical Issues: _________________________________________________________________________________
Behavioral/Social Issues: __________________________________________________________________________
Does your child need to take any regular medica/ons?

YES NO

If yes, please explain: ___________________________________________________________________________

Parent/Guardian #1 (Authorized to Pick Up Child)
First Name: __________________________________
Cell Phone: (

) - ______ - __________

Last Name: _______________________________

Other Phone: (

) - ______ - __________

Parent/Guardian #2 (Authorized to Pick Up Child)

First Name: __________________________________
Cell Phone: (

) - ______ - __________

Last Name: _______________________________

Other Phone: (

) - ______ - __________

EMERGENCY CONTACT INFORMATION (not listed above, but authorized to pick up child)
First Name: __________________________________
Cell Phone: (

) - ______ - __________

Last Name: _______________________________

Other Phone: (

) - ______ - __________

Emergency Contact Rela4onship: ______________________________________________________________

FELLOWSHIP BIBLE CHURCH ACTIVITY CONSENT/RELEASE & PHOTOGRAPHIC RELEASE FOR MINORS
Please note that we will be taking photos and videos of the ac4vi4es throughout the event. We use the photos and videos only for church related purposes, including posts to the Fellowship Bible Church website, social media, brochures, etc. If you wish to exclude your child(ren) from the photos and videos, please speak with
a FellowshipKids Team Member. By signing below, I give Fellowship Bible Church permission to publish in print, electronic, website, or video format the likeness or
image of my child. I release all claims against Fellowship Bible Church with respect to copyright, ownership, and publica4on, including any claim for compensa4on
related to use of the materials.
I, the undersigned parent or guardian, hereby consent to my child par4cipa4ng in the ac4vi4es connected with Fast Food Frenzy on January 6th, 2016 and that my
child is able to par4cipate in all ac4vi4es scheduled for this event. If my child has medical condi4ons which may be relevant to a physician in the event of an emergency, I have listed them above.
I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED DURING SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY
AND SUBSEQUENT THERETO. I do hereby agree to hold Fellowship Bible Church and their agents, volunteers and employees, harmless from any and all liability,
ac4ons, causes, claims, expenses, and damages on account of injury to my child or property, even injury resul4ng in death, which I now have or which may arise in
the future in connec4on with the ac4vity or par4cipa4on in any other associated ac4vi4es.
I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permi<ed by the law of the State of Oklahoma and
that if any por4on thereof is held invalid, it is agreed that the balance shall, notwithstanding, con4nue in full legal force and eect. This release contains the en4re
agreement between par4es hereto, and the terms of this release are contractual and not a mere recital.
I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT.
This is a legally binding agreement which I have read and understand.

Signature of Parent/Guardian _________________________________________________________________________________ Date _______________________

MEDICAL TREATMENT AUTHORIZATION AND CONSENT FORM

The following form is designed for those situa4ons where minors are unaccompanied by either parents or
legal guardians. This Medical Treatment Authoriza4on and Consent Form gives authority to a
designated adult to arrange for medical care for a minor in the event of an emergency. This is extremely
important, in that, medical care can not be provided to a minor without approval by the parents or legal
guardians, unless there is wri<en consent authorizing an agent to give approval.

Minors Full Name: _________________________________________________________________________

Minors Address: ___________________________________________________________________________
City, State, Zip Code: _______________________________________________________________________
Minors Birthdate: ___________

Minors Age: __________

The undersigned do hereby authorize Fellowship Bible Church and its agents to:
>> Obtain medical treatment and procedures for the child above as may be appropriate in emergency
circumstances, including treatment by physicians, hospital and clinic personnel, and other appropriate health
care providers.
>> Obtain rou4ne medical treatment from appropriate health care providers if symptoms of illness occur
(e.g., fever, coughing, irregular breathing, unusual rashes, swallowing problems, etc.)

This grant of temporary authority shall begin on January 6th, 2016, and shall remain eec4ve un4l
terminated by the undersigned.

Parent or Guardian Signature: ____________________________________

Date: _________________

Parent or Guardian (please print): _____________________________________________________________

Address Parent or Guardian: ________________________________________________________________

Home and Cell Phones of Parent or Guardian: ___________________________________________________

Insurer: ________________________________

Account Number: ________________________________