PERRY COUNTY, AL MISSION TRIP 2023

Participant Name

First Name

Last Name

T-shirt size

Small

Medium

Large

XXL

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Birthday

YYYY

Allergies / Restrictions

Is the participant listed above allergic to any medications, foods, environmental, or other substances?

Yes

If yes, please list allergen(s):

Is the participant listed above currently on any medications?

Yes

If yes, please describe:

Emergency Contacts

Please list anyone (parent/guardian and others) authorized to act on your behalf in the event of an emergency.

Please list phone numbers in the order we should call.

INFORMED CONSENT & AUTHORIZATION for EMERGENCY TREATMENT and TRANSPORTATION

I authorize First Baptist Church and its volunteers, staff and agents to provide first aid to the above named in accord with their judgment, and this treatment may include the administration of over-the-counter (non-prescription) medications and other medications when the above named needs medical care beyond first aid and over-the-counter (non-prescription) medications. I give my consent and permission for such medical care to be obtained and further give consent to any treatment recommended by the medical personnel consulted. I further understand that photos and videos will be taken and authorize the taking and publication of photographs and videos of the above named via the internet or other medium. I understand that travel may include church vehicles and private vehicles, and such vehicles will be driven by church staff, adult volunteers and/or paid staff. I further understand active indoor elements and outdoor activities will occur. I freely and voluntarily assume the risk of personal injury to the above named, even if the result of the negligence is First Baptist Church or its volunteers, staff, or agents, and further hold harmless First Baptist Church and its volunteers, staff, and agents and release any legal claims of any kind involving any and all injury, disability, death, or loss or damage to the above named or property, whether caused by the negligence of the releasees or otherwise.

Condition of Registration:

I have read, understand and agree to the terms and conditions listed on this Emergency Contact Form and I understand it is my responsibility to provide accident and health insurance coverage for listed participant and I will be financially responsible for all charges and fees for emergency medical treatment and/or transportation, regardless of whether my medical insurance covers such charges and fees.

Parent/Guardian or Participant Signature (Enter Name)

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Mission Trip 2023 Registration