Teen Ministries

Parent/Guardian Name *

This form must be filled out by the legal parent or guardian

First Name

Last Name

Teen Name *

First Name

Last Name

Teen's Date of Birth *

MM

DD

YYYY

Teen Cell Phone

If applicable

(###)

###

####

Parent/Guardian Cell Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent *

I understand that neither Bethel Baptist Church nor the insurance company will be responsible for medical treatment or liability resulting from physical conditions existing prior to my child(ren) attending or participating in activities with Bethel Baptist Church.

Agreed

Emergency Authorization *

I hereby give permission to the first aid personnel selected by Bethel Baptist Church Leadership to provide standard first aid care and administer over the counter medication, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Bethel Baptist Church Leadership to order x-rays, routine tests, hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child(ren) as named above.

Agreed

Hold Harmless Agreement *

Furthermore, as the parent or guardian for a minor child(ren) as named above who is in my care and custody, do hereby grant permission for my child to attend a program or event at Bethel Baptist Church.I fully understand the nature of recreational activities associated with the use of the church facilities and/or programs includes risk of danger, which may result in personal injury or harm to my child. I understand that my child will be under adult supervision at all times but, notwithstanding any level or degree of supervision, that accidents may occur which may result in physical injury or harm to my child. It is with the full understanding of the risks associated with these types of activities that I grant permission for my child to participate in the program to be conducted at Bethel Baptist Church, and Iagree to indemnify and hold harmless Bethel Baptist Church, its staff, directors, employees, agents and/or representatives from any claim for any injury or damage which may result from my child’s attendance and participation in programs and events conducted on church property.

Agreed

Permission *

Permission is granted for my child to participate and I understand that by signing this form I am voluntarily and knowingly accepting responsibility for my child’s participation in the activity or program to be conducted at Bethel Baptist Church.

Agreed

Transportation *

I agree not to hold Bethel Baptist Church Youth Ministry or any of it’s paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend, and hold harmless Bethel Baptist Church for all claims made and liabilities assessed against them as a result of any activity or event. I release Bethel Baptist Church and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from an event or activity.

Agreed

Do Not Agree (your child will not be able to participate in any activities using church transportation)

Photos *

I grant permission for pictures and images of my child to be taken while participating in activities and used for Bethel Baptist Church promotional purposes.

Agreed

Do Not Agree