VBS 56ERS ACTIVITY CONSENT AND RELEASE WAIVER

CHILD'S NAME *
CHILD'S NAME
PARENT/GUARDIAN NAME *
PARENT/GUARDIAN NAME
ADDRESS *
ADDRESS
PRIMARY PHONE *
PRIMARY PHONE
SECONDARY PHONE
SECONDARY PHONE
STUDENT DATE OF BIRTH
STUDENT DATE OF BIRTH
The youth listed above has permission to participate in an off-site outreach program of Vacation Bible School (June 17-21) through Decatur First United Methodist Church. Children will depart from the main church campus at 300 E. Ponce de Leon Ave., Decatur GA 30030, and travel (via church bus or van) to various non-profits. Activities take place between 8:45 am – 12:15 pm daily. I understand that participation in the activity involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself or my child to participate in the activity. I understand that participation in the activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release Decatur First United Methodist Church, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation including transportation to and from activity. I agree that my child’s likeness may be used by Decatur First United Methodist Church for promotion of Youth Ministry and Church events. In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. I understand that Decatur First United Methodist Church, Inc. does not carry accident or medical insurance on participants or volunteers. I agree that my insurance company will be used for such treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payment of any and all medical bills.
EMERGENCY CONTACT #1 (IN ADDITION TO NAME ABOVE) *
EMERGENCY CONTACT #1 (IN ADDITION TO NAME ABOVE)
EMERGENCY #1 PHONE *
EMERGENCY #1 PHONE
EMERGENCY CONTACT #2 (IN ADDITION TO NAME ABOVE) *
EMERGENCY CONTACT #2 (IN ADDITION TO NAME ABOVE)
EMERGENCY #2 PHONE *
EMERGENCY #2 PHONE