2008/2009 Bethany Baptist Church – SM Permission/Waiver Form

Name of student (please print)_______________________________________________________

Parent(s) and/or legal guardian(s) of student______________________________________________

Address_____________________________ City_________ State_________

Zip_______________

Home Phone_________________________________ Work Phone_____________________

Age of student__________________Birth Date________________ School Grade__________

School________________________________ Wear Glasses or Contacts?

Functions and Activities

It is my understanding that participating in the programs and recreational and other activities of Bethany Baptist
Church –Student Ministry (BBC-SM) is a privilege. Prior to my participation in such activities, I acknowledge
that there are certain risks associated with the activities, including, by way of example, physical injury due to
activity-related accidents, physical injury due to transportation related accidents, or even death. In addition, I
acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Release of Liability
By signing this permission/waiver form, I expressly warrant that the student named above is capable of
withstanding both the physical and mental demands of the activities discussed above. I also expressly assume
all risks of the student participating in the activities, whether such risks are known or unknown to me at this
time. I further release BBC-SM and its ministers, leaders, employees, volunteers and agents from any claim
that my student may have or that I may have against them as a result of injury or illness incurred during the
course of participation in the activities. This release of liability shall exclude any gross claims of negligence.
This release of liability is also intended to cover all claims that members of the student's or my family or estate,
heirs, representatives, or assigns may have against BBC-SM or its ministers, leaders, employees, volunteers, or
agents.

I further agree to indemnify and hold harmless BBC-SM and its ministers, leaders, employees, volunteers, or
agents from any and all claims arising from my participation in its activities and programs, or as a result of
injury or illness of my student during such activities.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the student named above may be in need of first aid emergency
medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give
permission for agents of BBC-SM to seek and secure any needed medical attention or attention for the student
named above, including hospitalization, if in the agent's opinion such need arises. In doing so I agree to pay all
fees and costs arising from this action to obtain medical treatment.

I give permission for attending physician(s) and other medical personnel to administer any needed medical
treatment, including surgery and, again, I agree to pay for the medical treatment.

Special Events and Field Trips

I understand that the student named above may be participating in local service projects and interactive events
during the BBC-SM events on Sunday and Wednesday evenings. I understand that during this period my
student may take part in activities that are consistent with the purposes of the church.

Health Insurance Information

Insurance Company_____________________ Ins. Co. phone number_____________________
Policy Number______________________________ Group Number______________________
Family Doctor______________________________ Phone Number______________________
Emergency Contacts
Name___________________________________
Relation_________________________________
Home Phone____________________________ Work Phone____________________________
Name___________________________________
Relation_________________________________
Home Phone____________________________ Work Phone____________________________

Swimming Ability
Non-Swimmer
Beginning (capable of swimming for several minutes in deep water)
Moderate (capable of several lengths of pool)
Advanced (capable of long distances)

Medical History
Special needs or concerns (allergies, conditions, dietary needs, medications, etc.):

Other Information
Other information leaders should know about the student participant:
For Use Only if the Participant is a Minor

I represent that I am the parent/guardian of_______________________who is under 18 years of

age. I have read the above Permission/Waiver Form and am fully familiar with the contents
thereof.

I give Permission for the student named above to participate in the activities of BBC-SM,
including any special events or activities described above. In consideration for allowing the
participation of the student in the activities of BBC-SM, I hereby consent to the
Permission/Waiver Form including the Release of Liability above, on behalf of the student, and
agree that this Permission/Waiver Form shall binding upon me, my family, heirs, legal
representatives, successors, and assigns.

Signature of Parent or Legal Guardian______________________________________________

Date_______________________

Print Name of Parent or Legal Guardian_____________________________________________

Witness Signature______________________________________

Date_______________________

Publicity
On occasion BBC-SM takes photographs or makes an audio or videotape recording of students
and/or adults involved in church activities. Such photographs or video records may be used by
staff and participants to remember the activities and participants. In addition, such photographs
and audio/visual records may be used by BBC-SM publications or advertising materials to let
others know about our ministry. In addition, local news organizations may hear of our activities
or events, and our church may invite or allow them to photograph or record our events for news
reporting on special interests features. I consent to the use of any (appropriate) such audio or
visual record of the student named above to be used, distributed or displayed as agents of the
church see fit. This consent includes but is not limited to: photographs, videotape, and audio
recordings (appropriate in nature). Furthermore, I give permission for the child to be
interviewed by the news media, or for such photographs and other audio or visual records to be
used by the news media.

Signature of Parent or Legal Guardian______________________________________________

Date_______________
Dear Parents,

If you've ever filled out one of our permission forms before, you know that it's neither the most
convenient or detailed form available for such purposes. That's why I've been searching for a
better way to make sure we have accurate medical and permission information on file in the
event of an emergency during a student ministry event.

The enclosed form should be filled out and returned to me as soon as possible if your
student will be attending ANY Bethany Baptist Church events. If you're familiar with the
old forms, you'll find this to be much more detailed and comprehensive. Here's how we'll be
using it...

 All forms will be kept on file for one year. New forms will be sent out each summer
for you to complete before the next school year begins.
 If your medical information changes during the school year, please contact me to
update the information.
 Copies will be given to adult leaders for them to carry with them during events or
service projects. Of course, they will be required to keep medical information private
and accessible only by those individuals who have legitimate reasons to see it.
 You will NOT have to fill this form out each time there is an event. Instead, a brief
permission form will be sent out for you to give consent for your student to attend
special events such as lock-ins, retreats, concerts, work trips, etc..

Again, please return this form as soon as possible to my attention at the church. Please don't
hesitate to call if you have any questions.

Jason Davis
Associate Pastor

Revised: 9/24/08:jd
A resource of BBC Student Ministry