Mount Ararat Baptist Church Risk Acknowledgement

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Mount Ararat Baptist Church Risk Acknowledgement, Video/Photo Release, Medical Release Full Name of Participant ________________________________________________________ Address _____________________________________________________________________ City/State/Zip _________________________________________________________________ Cell Phone ______________________________

Birthdate (mm/dd/yyyy) ______________

Mount Ararat Baptist Church strives to provide safe environments for adults and children in its programs. However, not all circumstances can be anticipated and some risks cannot be eliminated. A permission slip must be submitted for any individual participating in a church activity, trip, or event that takes place at or away from the church.

Name of Activity/Event ___________High School Soap Hockey & Water Slide_____________ Dates of Activity/Event ____________June 27th, 2018________________________________ Risk Acknowledgement I hereby certify that I am in good physical and mental health at this time, and wish to participate in the above event/activity. I understand that my participation may result in an unexpected illness or injury, due to accidents, forces of nature, or other unforeseeable events. Such illnesses or injuries could include diseases, strains, sprains, fractures, dislocations, and/or death. These injuries (if incurred) could cause permanent disabilities. I realize that there are certain risks, including death, arising from this activity, and I am willing to assume such risks. Video/Photo Release I also understand that I and/or my child(ren) may be video-taped or photographed for promotional purposes. By signing this release form, I authorize the church to use my and my family’s picture(s) (including photographic and video images) and my and my family’s voice(s) (including sound and video recordings) in any and all media and the Internet. I also waive the right to receive any payment. Medical Release In the case of an emergency while the named individual is in the care of Mount Ararat Baptist Church, the church will notify the emergency persons listed immediately. In the event the church is unable to reach these persons, the church party responsible and or its designated staff is authorized to seek and obtain medical attention, treatment, and services as may be deemed necessary until the guardian arrives. The guardian agrees to pay all medical costs incurred.

In Case of Emergency Notify Name____________________________________ Cell Phone __________________________ Name ___________________________________ Cell Phone __________________________ Allergies (List all allergies to medicines, foods, or other things) _____________________________________________________________________________ Signature of Guardian (If participant is under 18 years old) Date ________________________________________________ Print Name ______________________________________

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