Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Emergency Contact (must be a different person/phone number than what is listed above) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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By clicking these check boxes, I agree that *

I am the parent/legal guardian of the child listed on this registration, and my child has my permission to participate in (youth event)

I hereby release First Baptist Church Valley Mills and its directors, employees and volunteers from responsibility and liability for any injury or illness that my child may sustain during (youth event)

I voluntarily waive any claim against First Baptist Church Valley Mills, the volunteers, employees , and the owner/driver of the car , van, or bus providing transportation to and from (youth event)

In the event of an emergency, I give my permission to those in charge to stop any bleeding and administer first aid, and hereby authorize an adult leader of this activity, as an agent for me, to consent to any x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician or surgeon.

First Baptist Church Valley Mills has my permission to post pictures/video of my child to fbcvm.org and social media platforms (Facebook, Instagram etc.) for promotional purposes