EVENT REGISTRATION

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SAVE THE DATE

VBS 2021

PARTICIPANT CONSENT FORM (PARTICIPANTS INCLUDE CHAPERONE, YOUTH, OR CHILD)

Please complete the following Event Consent Form to participate as a Chaperone or a Youth/Child participant. (Must be updated Annually for each participant.)

List of some events that require a Consent Form:

Preteen Summer Camp
Preteen Retreat
Events that require travel more than 2 hours from the church.
Events that require an overnight stay.

Consent Form - Chaperone or Child (1st - 6th Grade)

PARTICIPANT CONSENT FORM

Participant Name*

Date of Birth*

Mailing Address*

Participant Home Phone Number (Landline)( ) -

Participant Cell Phone( ) -

EMERGENCY CONTACT INFORMATION

Primary Emergency Contact Name*

Relationship to Participant*

Cell PHone - Primary Emergency Contact( ) -

Primary Emergency Contact Alternate Phone Number ( ) -

Secondary Emergency Contact*

Relationship to Participant*

Cell Phone - Secondary Emergency Contact( ) -

Secondary Emergency Contact Alternate Phone Number( ) -

MEDICAL INFORMATION

Your Physician/Doctor

Physician/Doctor Phone( ) -

Your Hospital Name

Hospital Phone( ) -

Your Pharmacist

Pharmacist Phone( ) -

Do you have Health Insurance?*

Upload Image of Front of Health Insurance Card (PDF, png, jpg)

Upload Image of Back of Health Insurance Card (PDF, png, jpg)

Name of Insurance Company

Policy Number

Social Security Number

Health Insurance Address

List any medications being taken (include any over-the-counter medications taken daily):

List any Allergies:

List any life-threatening physical problems:

Date of last Tetanus injection

List any known medical complications:

Is there anything else that our staff/workers/adults need to know about the above participant that would be beneficial to the health or well-being of the participant? (Medication directions, activiey directions, etc.):

EVENT INFORMATION

I, the undersigned participant or parent/guardian of the above named participant, hereby grant permission for the participant to participate in ACTIVITY:

Please acknowledge each statement below by clicking each check box.*

We have been advised of the nature and extent of the activities that may take place, and represent to you that the participant is physically and mentally able to participate in these activities.

I, the undersigned participant or parent/guardian of the above named participant, hereby authorize on our behalf, such medical and hospital treatment as you may deem advisable for the health and well being of the participant.

On behalf of the participant and myself, I hereby release Philadelphia Baptist Church of Deville, LA, it's pastors, teachers, activity supervisors, student workers, any and all members, and volunteers in the above named activity. I agree to defend and hold you harmless against any claims or liabilities asserted against you at any time on behalf of the participant by reason of such participation or any other matter or thing to which this Consent Form appertains.

The activity begins at Philadelphia Baptist Church, Deville, LA on (enter date).

and the participant should return on approximately (enter date)

Check all boxes that apply.*

I authorize transportation by Philadelphia Baptist Church.

I am aware that the activity WILL involve swimming or water sports.

I am aware that the activity WILL NOT involve swimming or water sports.

This form must be signed and submitted electronically prior to departure. Only those who submit this form properly filled out and electronically signed can be granted permission to participate.

SIGNATURE

I constitute that by entering Parent/Guardian name or Chaperone Participants name below I am electronically signing this Consent Form.*

Signature Date*