Youth Emergency Contact Form, Berea Baptist Church

Parent/Guardian Name *

First

Last

Email *

Child's/Childrens names and ages

Parent/Guardian Name(s)

Phone number for Parents/ Guardian(s)

Other Individual named as an Emergency Contact, and their phone number if I cannot be reached

Are there any health concerns we should be aware of?

Allergies, Dietary Restrictions etc.

I give permission for my child/children to take part in Berea Baptist Church Activities and agree that the Leadership team of Berea Baptist Church will not be held responsible for any injuries or illnesses that my ward sustains at a Berea Baptist Church Activity. I hereby authorize an adult leader of Berea Baptist Church, to act as an agent of myself, in seeking emergency medical treatment, if deemed necessary for my child, in the event that I cannot be contacted in an emergency, I authorize the physician or hospital selected by the leader to provide treatment, including hospitalization, for my child. I also surrender my child’s legal right to their electronic image, and permit usage of it/them for in house presentations/ or on the Berea Baptist Church Website. *

Electronic Signature: By signing here you are verifying that this signature identifies you as the legal Guardian/Parent of this child/children.