Holly Springs Baptist Church Release Form Effective dates: August 13, 2017 to August 30, 2018Name: First Last Age: Birthdate:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearYear in school: Gender:MaleFemaleE-mail:Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryPhone: Home Area Code - Phone Number Phone: Cell Area Code - Phone Number Mother's name: First Last Mother's Phone: Home Area Code - Phone Number Mother's phone: Cell Area Code - Phone Number Father's name: First Last Father's phone: Home Area Code - Phone Number Father's phone: Cell Area Code - Phone Number Emergency contact: First Last Emergency contact phone: Home Area Code - Phone Number Emergency contact phone: Cell Area Code - Phone Number Physician: First Last Physician Phone: Area Code - Phone Number Dentist Name: First Last Dentist Phone: Area Code - Phone Number Medical HistoryMedical Profile Generally, the participant's Health is:ExcellentGoodFairPoorIf Fair or Poor, please explain the condition: List any medical difficulties which are currently being treated: Check any of the following that cause you problems & explain:AsthmaDizzinessSinusitisStomachBronchitisUpsetKidney TroubleHay FeverHeart TroubleDiabetesExplain any of the above problems: List any medicines or substances to which you are allergic: List any previous operations or serious illnesses: List any medications you are currently taking: List any special diet or special needs: Childhood Diseases:ChickenpoxMeaslesMumpsWhooping CoughOtherPlease explain if you answered "other" above: Date of Tetanus Immunization:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearFamily Physician: Family Physician Phone: Area Code - Phone Number Insurance Co: Policy #: Subscriber Name: Subscriber Number: Employment: Subscriber Occupation: Work Phone: Area Code - Phone Number For your information, we expect each student to conform to these rules of conduct:No possession or use of alcohol, drugs or tobaccoNo fighting, weapons, fireworks, lighters or explosivesNo offensive or immodest clothingNo boys in girls' sleeping quarters and no girls in boys' sleeping quartersFull participation with the group is expectedRespect propertyRespect one another, staff and adult leadersRespect and comply with event schedulesDemonstrate the fruits of the Spirit in all situationsStudents who fail to comply with these expectation may have their privileges suspended and may be sent home at their parents' expense.I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct.Student Signature: First Last Date:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearActivities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller-skating, rollerblading, games in the park, skateboarding, soccer, ice skating, volleyball, softball, baseball, paintball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: Transportation to and from events and activities held off of the church's campus will be provided by Holly Springs Baptist Church who will enlist responsible adults to operate the vehicles. If you wish to limit your child's participation in any event or activity, please submit your wish in writing to the Minister of Youth.Student Name First Last has my permission to attend all youth activities sponsored by Holly Springs Baptist Church from August 30, 2016 to August 30, 2017.Permission for Medical Treatment, Photography/Video Notice and Release and IndemnityI/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by Holly Springs Baptist Church. I/We understand that there are inherent risks involved in any ministry or athletic even, and I/we hereby release the Church, its ministers, employees, agents and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at the date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. Also, I/we understand that as a participant, my child may be photographed or videotaped during normal church or event activities, and these photos/videos may be used in promotional materials.I, the undersigned, do hereby verify that the above information is correct, and I do hereby release and forever discharge Holly Springs Baptist Church from any and all claims, costs, demands, actions or causes of action, past, present or future arising out of any damage or injury in connection with my or my child's employment by or participation in any church events.Parent/guardian signature: First Last Signature Date:01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearSubmitResetWord Verification:
