2017-2018 Parent Permission Form

*Valid for all Catawba Valley Baptist Church sponsored activities and events, and for church transportation, for one year from the date of submission.

Student Name

First NameMiddle NameLast Name

Group

Gender

Birthdate

Date

Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Email

example@example.com

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

Primary Physician

Physician Phone Number

Area CodePhone Number

Name of Health Insurance Company

Type "none" if not applicable

Policy or Group Number

Health Insurance Company Phone Number

Area CodePhone Number

Medical Problems/Allergies/Food Restrictions

Type "none" if not applicable

Medications Taking

Type "none" if not applicable

Activity Restrictions, if any

Type "none" if not applicable

Date of Last Tetanus Shot

Contact Lenses

Yes/No

Other

READ CAREFULLY - THIS SECTION AFFECTS YOUR LEGAL RIGHTS

In exchange for participation in on-site and off-site activities and events sponsored by Catawba Valley Baptist Church (CVBC), and/or use of the property, facilities and/or services of CVBC, I agree to the following for myself and, if applicable, for my child:&#13;&#10;&#13;&#10;1. I hereby give permission for photographs, audio recordings, and video recordings of me or my child captured during any CVBC-sponsored activity or event to be used by the church for training and/or promotional materials and publications, and I waive any rights to compensation or ownership. &#13;&#10;&#13;&#10;2. I give permission for CVBC staff, representatives, and/or volunteers to search my child’s belongings including but not limited to luggage, purses, and backpacks, as deemed necessary for safety and security purposes.&#13;&#10;&#13;&#10;3. I hereby give permission for me or my child to ride in a vehicle designated by CVBC staff. Only adult drivers age 21 or older with approved driving records will be permitted to drive.&#13;&#10;&#13;&#10;4. In the event that I or my child causes damage to property, I accept full financial responsibility for those damages. In addition, if an early return home is warranted due to disciplinary concerns, I will provide transportation home for myself and/or my child.&#13;&#10;&#13;&#10;5. I recognize that there are certain potential and inherent risks associated with participation in CVBC-sponsored activities and events, and I assume full responsibility for personal injury to myself and, if applicable, my child. I further release, hold harmless, indemnify, and discharge CVBC, its staff, officers, directors, board members, volunteers, and agents from injury, loss or damage arising out of my or my child's participation in CVBC-sponsored activities and events, whether caused by the fault of myself, my child, CVBC, or any third party.&#13;&#10;&#13;&#10;6. I agree to indemnify and defend CVBC against all claims, causes of action, damages, judgments, costs, or expenses, including attorneys' fees and other litigation costs, arising out of my or my child's participation in CVBC-sponsored activities and events.&#13;&#10;&#13;&#10;7. In the event of an injury to me or my child during a CVBC-sponsored activity or event, I give permission to CVBC and its employees, representatives, or agents to arrange for necessary medical treatment, for which I shall be financially responsible. This authorization begins on the date of signature and remains in effect for one year, unless sooner revoked in writing and delivered to CVBC. CVBC shall have the authority to seek appropriate medical treatment or attention on behalf of me or my child as circumstances may require, including treatment by a licensed physician and/or hospital; to authorize emergency medical treatment or procedures; and to make appropriate decisions regarding clothing, nourishment, and shelter. &#13;&#10;&#13;&#10;8. I hereby consent and give permission for me or my child to participate in on-site and/or off-site CVBC-sponsored activities and events, and I agree, on behalf of the minor named above, to all terms and conditions of this agreement. By signing this Release of Liability, I represent that I have legal authority over and custody of the child named above. This agreement shall be governed by the laws of the Commonwealth of Virginia, and the assumption of risk and release provisions contained herein are intended to be as broad and inclusive as permitted by law.

I AGREE TO THE ABOVE TERMS AND CONDITIONS

I ,the Parent/Guardian, do hereby agree with the statements and terms above, and certify all the information stated to be true (Signature):

I ,the Parent/Guardian, do hereby agree with the statements and terms above, and certify all the information stated to be true (Print Name):

Date

Name

First NameLast Name

Parent Permission Form

Student Info:

Parent/Guardian Info:

Emergency Contact and Medical Information

Terms, Conditions, and Statement of Release: