Back2School Registration

  • I, (please print)_________________________________acknowledge that I have volunteered to participate in the with the Student Ministry of Main Street Baptist Church. I am aware that I am voluntarily participating in these activities which include, but are not limited to, transporting to and from the activities and related activities, with the knowledge of the danger involved. I hereby agree to accept any and all risk of injury and verify this statement by placing my signature below. I hereby agree that I, my assignees, heirs, distributes, guardians, and legal representatives will not make a claim against, sue, or attach the property of Main Street Baptist Church, its staff, trustees, chaperones, volunteers, or members. This release is intended to be broad in its effect. I authorize a Main Street Baptist Church staff member and/or chaperone to obtain medical treatment for my child in the event of injury or illness and agree to pay any expenses incurred for treatment. PARTICIPANT NAME: DOB: ADDRESS: CONTACT: PHONE: INSURANCE CARRIER: POLICY NUMBER: ALLERGIES: DATE OF LAST TETANUS SHOT: IMPORTANT MEDICAL INFO: SIGNATURE OF PARTICIPANT: DATE: SIGNATURE OF PARENT/GUARDIAN: DATE: PLEASE ATTACH A COPY OF INSURANCE CARD.