SBC Student Child Permission Medical Photo Release Form 2022-2023
Student’s Name: ________________________________________ Date of Birth: _____________________________________________________
Address: _____________________________________________________________________________
Name of Parent/Guardian: _____________________________________________________________________________
Relationship with Student: ________________________________ Home Phone: _____________________________________________________
Work Phone: ___________________________________________ Cell Phone: _____________________________________________________
Name of Parent/Guardian: _____________________________________________________________________________
Relationship with Student: ________________________________ Home Phone: _____________________________________________________
Work Phone: ___________________________________________ Cell Phone: _____________________________________________________
Persons to call if Parent or Guardian cannot be reached in case of emergency:
Name: _______________________________________________ Phone: _____________________________________________________
Name: _______________________________________________ Phone: _____________________________________________________
Health Insurance Provider: _____________________________________________________________________________
Policy #:______________________________________________
Are there any special health conditions of which Sharon Baptist Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)? (Please check one) ☐ No ☐ Yes
If the answer to the preceding question was “Yes,” please explain:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Does your child know how to swim? (Please check one) ☐ No ☐ Yes If yes: ☐ Beginner ☐ Intermediate ☐ Advanced
PERMISSION AND RELEASE
As the parent (or guardian) of the above-named attendee, I grant permission for my son or daughter to attend Sharon Baptist Church’s 2022-2023 activities and events and authorize Sharon Baptist Church and its chaperons, to transport and supervise my child in connection with his or her attendance at the various activities throughout 2022-2023.
I do further hereby give, release, absolve, indemnify, and agree to hold harmless, Sharon Baptist Church, its trustees, staff, volunteers, and persons transporting my son/daughter to and from the activity and associated activities from any claim arising out of injury to my son or daughter, except to the extent such harm is the result of the intentional misconduct of Sharon Baptist Church or such other party seeking to enforce this release.
Signature:_____________________________________________ Date: _____________________________________________________
Name (please print):_____________________________________________________________________________
Please continue on back…
MEDICAL CARE AUTHORIZATION
As the parent (or guardian) of the above-named attendee of Sharon Baptist Church’s student activities, I hereby authorize Sharon Baptist Church and its chaperones to seek and have emergency medical first aid administered to the above-named attendee during 2022-2023.
Signature: _____________________________________________ Date: _____________________________________________________
Name (please print): _____________________________________________________________________________
WAIVER OF PUBLICITY FORM
I give permission for the use of any photos, movies, and audio or video tapings of my child’s activities in connection with Sharon Baptist Church’s student ministry, to be used with SBC’s approval for educational or religious purposes, media coverage, or for publicity benefiting educational or religious purposes.
Signature: _____________________________________________ Date: _____________________________________________________
Name (please print): _____________________________________________________________________________
Relationship to Student: __________________________________
Student’s Name: ________________________________________ Date of Birth: _____________________________________________________
Address: _____________________________________________________________________________
Name of Parent/Guardian: _____________________________________________________________________________
Relationship with Student: ________________________________ Home Phone: _____________________________________________________
Work Phone: ___________________________________________ Cell Phone: _____________________________________________________
Name of Parent/Guardian: _____________________________________________________________________________
Relationship with Student: ________________________________ Home Phone: _____________________________________________________
Work Phone: ___________________________________________ Cell Phone: _____________________________________________________
Persons to call if Parent or Guardian cannot be reached in case of emergency:
Name: _______________________________________________ Phone: _____________________________________________________
Name: _______________________________________________ Phone: _____________________________________________________
Health Insurance Provider: _____________________________________________________________________________
Policy #:______________________________________________
Are there any special health conditions of which Sharon Baptist Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)? (Please check one) ☐ No ☐ Yes
If the answer to the preceding question was “Yes,” please explain:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Does your child know how to swim? (Please check one) ☐ No ☐ Yes If yes: ☐ Beginner ☐ Intermediate ☐ Advanced
PERMISSION AND RELEASE
As the parent (or guardian) of the above-named attendee, I grant permission for my son or daughter to attend Sharon Baptist Church’s 2022-2023 activities and events and authorize Sharon Baptist Church and its chaperons, to transport and supervise my child in connection with his or her attendance at the various activities throughout 2022-2023.
I do further hereby give, release, absolve, indemnify, and agree to hold harmless, Sharon Baptist Church, its trustees, staff, volunteers, and persons transporting my son/daughter to and from the activity and associated activities from any claim arising out of injury to my son or daughter, except to the extent such harm is the result of the intentional misconduct of Sharon Baptist Church or such other party seeking to enforce this release.
Signature:_____________________________________________ Date: _____________________________________________________
Name (please print):_____________________________________________________________________________
Please continue on back…
MEDICAL CARE AUTHORIZATION
As the parent (or guardian) of the above-named attendee of Sharon Baptist Church’s student activities, I hereby authorize Sharon Baptist Church and its chaperones to seek and have emergency medical first aid administered to the above-named attendee during 2022-2023.
Signature: _____________________________________________ Date: _____________________________________________________
Name (please print): _____________________________________________________________________________
WAIVER OF PUBLICITY FORM
I give permission for the use of any photos, movies, and audio or video tapings of my child’s activities in connection with Sharon Baptist Church’s student ministry, to be used with SBC’s approval for educational or religious purposes, media coverage, or for publicity benefiting educational or religious purposes.
Signature: _____________________________________________ Date: _____________________________________________________
Name (please print): _____________________________________________________________________________
Relationship to Student: __________________________________