Rock Branch Baptist Church // Rooted Youth Permission/Medical Release Form

2150 Coldwater Rd Elberton, GA 30635

THIS FORM IS FOR ALL 2024 & 2025 YOUTH MINISTRY ACTIVITIES, EVENTS, RETREATS & TRIPS

Student First Name

Student Last Name

D.O.B.

Age

Grade

Parent Guardian's First Name 1

Parent Guardian's Last Name 1

Parent/Guardian's Phone Number 1

Parent Guardian's First Name 2

Parent Guardian's Last Name 2

Parent/Guardian's Phone Number 2

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

PERMISSION

I do hereby verify the information given on this form is correct.
I do hereby give permission for my above-named child to participate in and to be transported to and from ALL activities, events, retreats or trips sponsored by the Youth Ministry of ROCK BRANCH BAPTIST CHURCH, Elberton, GA during 2024 & 2025.
I understand that this permission/release will apply to all planned activities, events, retreats and trips sponsored by the Youth Ministry of ROCK BRANCH BAPTIST CHURCH during the 2024 & 2025 years,
I understand that, in the case of an emergency ROCK BRANCH BAPTIST CHURCH, employees, agents and/or sponsors will make every effort to contact me and/or the contact person named below, however;
Should the named contact person, or myself, be unavailable to make decisions regarding my child’s care, I do hereby grant permission for ROCK BRANCH BAPTIST CHURCH employees, agents and/or sponsors to obtain emergency medical attention in case of sickness or injury, to my child.
Should the named person or myself, be unavailable to make decisions regarding my child’s care, I do hereby grant permission for an attending physician or hospital to perform whatever care is deemed necessary by ROCK BRANCH BAPTIST CHURCH employees, agents and/or sponsors for the welfare of my child.

Initials

HOLD HARMLESS

In consideration for you allowing my child to go on said activities, events, retreats or trips:

I hereby release, absolve, indemnify, hold harmless, and forever discharge
ROCK BRANCH BAPTIST CHURCH, its employees, agents, organizers, sponsors, or any supervisors appointed by them from any and all claims, demands, actions or cause of actions, past, present, or future arising out of injury or damage to my child while participating in any activity, event, retreat or trip.
I assume all risks and hazards incidental to the conduct of the activities, events, retreats or trips and transportation to and from these activities, events, retreats or trips. In case of injury to my child, I hereby waive all claims against ROCK BRANCH BAPTIST CHURCH, its employees, agents, organizers, sponsors, or any supervisors appointed by them. I likewise release from responsibility any person transporting my child to and from said activities, events, retreats or trips.
I agree that any dispute, claim, questions, or disagreement arising out of or relating to said activities, events, retreats or trips, which cannot be otherwise resolved shall be submitted to mediation and if necessary legally binding arbitration as adopted by the Administrative Office and legal counsel. As a result, I expressly waive any and all rights at law and equity to bring any civil matter before a court of law, except that judgment upon the award rendered by the arbitrator may be entered in any court have jurisdiction thereof.
I agree to provide medical insurance for my child.

Initials

PHOTOGRAPHY CONSENT

I understand that ROCK BRANCH BAPTIST CHURCH regularly photographs, or records by other visual or sound recording devices during our worship services, Sunday School and other church sponsored activities, events, retreats and trips. In consideration for allowing my child to participate in said activities, events, retreats and trips, I consent to my child’s photograph, likeness or image being used by
ROCK BRANCH BAPTIST CHURCH in video presentations, publications, promotions, on their website and social media websites or in any other lawful manner.

Initials

MEDICAL INSURANCE INFORMATION

Family Insurance Company

Policy #

Family Physician

Physician Phone #

Other medical conditions explain here :

Allergies (If none please put N/A)

Medications that we need to be aware of : (Please give name of medication, dosage, & when it needs to be administered)

Emergency First Name 1

Emergency Last Name 1

Emergency Phone 1

Emergency First Name 2

Emergency Last Name 2

Emergency Phone 2

Signature of Father or Legal Guardian

Today's Date

Signature of Mother or Legal Guardian

Today's Date