Fillable Printable Heritage Baptist Church Registration Form

Heritage Baptist Church Registration Form

Heritage Baptist Church Registration / Permission Forms

Activity or Event: ____________________________________ Date(s): _____________________

A new and separate form is required for each activity or program where adults or children

are transported to / from activities or events away from the Heritage Baptist Church campus.

ADULT PARTICIPANT comp lete sections A - C - D - F

CHILDRENORYOUTHPARTICIPANTcompletesectionsB‐C‐D‐E–F

A. GENERAL INFORMATION (ADULT PARTICIPANT)

Participant: _________________________________________________ Male _____ Female _____

Street Address: _____________________________ City: ______________________ Zip: _________

Home Phone: (____)_____________Work: (____)________________Cell:(____)_________________

Email: __________________________________________________________________________________

B. GENERAL INFORMATION (CHILD OR YOUTH PARTICIPANT)

Participant: ___________________________________________________Male _____ Female _____

School: _________________________________________________________ Age: _____Grade: _____

Home Address: ______________________________ City: ______________________ Zip: _________

Home Phone: (____)____________Cell: (____)_________ Email: _____________________________

Is there anyone your child should “not” be released to? _____________________________

PARENT / GUARDIAN INFORMATION

Name of Parent / Guardian: ___________________________________________________________

Home Address: ______________________________City: ______________________ Zip: _________

Home Phone: (____)________________ Work: (____)___________Cell: (____)___________

Email: _________________________________________________________

C. EMERGENCY CONTACTS

Name Contact: _________________________ Relationship: _______________________________

Home Phone: (____)_____________Work: (____)_______________ Cell: (____)_________________

Name Contact: __________________________ Relationship: _______________________________

Home Phone: (____)_______________Work: (____)_____________Cell: (____)_________________

D. HEALTH / INSURANCE INFORMATION

Health Insurance Co. ___________________ ID/Policy # ______________Group # ___________

Family Doctor: _____________________________________________ Phone# ___________________

MedicalProblems/Allergies:____________________________________________________________

Special DietaryNeeds:_________________________________________________________________

Current Medications:___________________________________________________________________

E. LIABILITY RELEASE (Children & Youth): Release of all claims

In consideration for participation in ____________________________________(event),

sponsored by Heritage Baptist Church, we (I), being 21 years of age or older, do

for ourselves (myself) (and on behalf of my minor child or student-participant if

said student is not 18 years of age or older) do hereby release, forever discharge

and agree to hold harmless Heritage Baptist Church and the directors thereof

from any and all liability, claims, or demands for personal injury, sickness or

death, as well as property damage and expenses, of any nature whatsoever

which may be incurred by the undersigned and the child / student–participant that

occur while said student is participating in ministry activities of Heritage Baptist

Church.

Furthermore, we (I) (and on behalf of our (my) child / student-participant if

under the age of 18) hereby assume all risk of personal injury, sickness, death,

damage and expense as a result of participation in recreation and work activities

involved therein.

Further, authorization and permission is hereby given to said church to

furnish any necessary transportation, food and lodging for this participant. The

undersigned further hereby agree to hold harmless and indemnify said church, its

directors, employees and agents, for any liability sustained by said church as the

result of the negligent, willful or intentional acts of said participant, including

expenses incurred attendant thereto.

(If the participant has not attained the age of 18)

We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant

our (my) permission for him/her to participate fully in said activities, and hereby

give our (my) permission to take said participant to a doctor or hospital and

hereby authorize medical treatment, including but not in limitation to emergency

surgery or medical treatment, and assume the responsibility of all medical bills, if

any.

Further, should it be necessary for the participant to return home due to

medical reasons, disciplinary action or otherwise, we (I) hereby assume all

transportation costs.

Signature:_________________________________________________ ___________________

Parent/Legal Guardian

Date

For more information or if you have questions call the church office at

423.926.9856

F. MEDIA RELEASE

I, the undersigned, do hereby grant or deny permission to Heritage Baptist

Church, Johnson City, TN. to use the image of myself or my child as marked by

my selection(s) below. Such use includes the display, distribution, publication,

transmission, or otherwise use of photographs, images and/or video taken of

myself or my child for use in materials that include, but may not be limited to,

printed materials such as brochures and newsletters, videos, and digital images

such as those on the Heritage Baptist Church Web site.

□ Deny permission to use my image or my child’s image at all.

□ Grant permission to use my image or my child’s image.

Signature:_________________________________________________ ___________________