Consent and Release Form

CONSENT AND RELEASE FORM
FOR FIRST BAPTIST CHURCH?S ACTIVITIES

I, the undersigned parent(s) or guardian(s), hereby consent to my child ___________________, who is _______years of age, participating in the activities connected with First Baptist Church of Fowlerville. This activity is sponsored by the First Baptist Church of Fowlerville, located at 214 S. Grand Ave., Fowlerville, MI., phone number (517) 223-9084, on the following date(s):___________________________. I understand that activities will include the following: ________________________________________________________.
I certify that my child is able to participate in any and all of these activities unless otherwise specified. I do not wish my child to participate in the following activities: ___________________
____________________________________________________________________________.
If there are any food/snack items that I do not want my child to have, they are listed as follows: ______________________________________________________________________
If my child has medical conditions, which may be relevant to a physician in the event of an emergency, I have listed them below. In the event that an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached within a reasonable period of time, as determined by the church officials, I hereby authorize the church or the adult sponsor(s) _______________________________________ to make emergency medical decisions for my child.


I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL THE RISKS WHICH MAY BE ENCOUNTERED ON THE SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO.
I, do, for myself and for my child, heirs and assigns, hereby irrevocably and unconditionally release, acquit and forever discharge First Baptist Church of Fowlerville, MI. and its agents, employees, and volunteers from any and all liabilities, actions, causes of actions, claims, expenses, obligations and damages of any nature whatsoever, which I now have or which may arise in the future, in connection with my child?s participation in the described activity or in any other associated activities including, but not limit to, any injury to my child or property, even injury resulting in death.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Michigan and that is any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto.

I further state that I HAVE CAREFULLY READ AND UNDERSTAND THE FOREGOING RELEASE AND KNOW THE CONTENTS HEREOF AND I SIGN THIS RELEASE ON MY OWN FREE ACT. I understand that this is a legally binding agreement.

MEDICAL CONDITIONS/ALLERGIES (TO MEDICATIONS) TO BE AWARE OF:__________________________

___________________________________________________________________________________________

PHYSICAL RESRTICTIONS: ___________________________________________________________________

MEDICATION AND INSTRUCTIONS: _____________________________________________________________

DATE OF LAST TETNUS BOOSTER: ____________________________________________________________

Parent/Guardian__________________________ Parent/Guardian______________________________

Date____________________________________ Date________________________________________

Telephone numbers where I may be reached in an emergency:

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