Activity Permission

Child's/Youth's Name
Age
Gender
Date of Birth
Current Grade Level (Just completed):
Address
Parents/Guardians
Primary Email
Alternate Email (if any)
Emergency Contact Name
Emergency Contact Number
Medical Insurance Company:
Any Medical Restrictions from Activities: Any Medications or Food Allergies: Any Other Special Needs:
If yes, explain:
Activity:

I understand that by submitting this form gives permission for my son/daughter to take part in the above named activity. I fully recognize that any activity involves an element of risk, and I/we assume responsibility for all risks and hazards incidental to my chil's/youth's participation in this activity. I/we hereby release, absolve, indemnify, and agree to hold harmless First Baptist Church of Vienna, its employees and officers, chairpersons, leaders, organizers, sponsors and persons transporting my/our child/youth to and from this activity. I have read this release, understand all its terms, and execute it voluntarily and with full knowledge of its significance.

Provide any payment required for this activity in the form of a check or money order payable to the First Baptist Church of Vienna and mail or bring payment to the church office, to the attention of Rev. Maurice Maxwell. Thank you!