Fellowship Baptist Church Youth Ministry Permission Forms Fellowship Baptist Church, Youth Ministry, and Volunteers Are Designated By The Abbreviation FBC Throughout This Entire Form GENERAL PERMISSION SLIP & RELEASE OF LIABILITY (Page 1) I, the parent/legal guardian of give my permission for my son/daughter to travel with and participate in activities with representatives of FBC. I understand that the safety and wellbeing of all members of the trip and/or activity will be the most important concern of the trip leaders. I hereby authorize FBC to include child in supervised water activities. I hereby authorize FBC its acting leaders to teach and lead my child in religious lessons and services, which include prayer and Bible teaching. In case of an emergency with my child, if I cannot be reached or if there is not sufficient time to reach me, I authorize the trip leaders to exercise their best judgment in handling an emergency situation. I understand that every effort will be made to contact me before these actions are taken. I will not hold the trip leaders responsible, legally or otherwise, for their actions, so long as these actions do not involve gross negligence or willful misconduct on the part of the trip leaders or FBC. In an emergency, illness, injury, or accident which requires medical attention, I hereby authorize and consent to any examination, anesthetic, medical or surgical diagnosis rendered under the general or specific supervision of any licensed medical personnel on the staff of any licensed hospital. This authorization is given in advance of any specific diagnosis, treatment, or care required, but is given to provide authority and power to render care that is deemed advisable in the best judgment of the physician. It is understood that an effort will be made to contact me prior to rendering treatment, but that any of the above treatment will not be withheld if I cannot be reached. The undersigned will furnish payment or insurance for any such payment, at his/her expense. I specifically authorize FBC or its representative to authorize medical care of me or my child while in the care of FBC to the greatest extent permitted by law. The undersigned represents to FBC that he/she is the natural parent or legal guardian of the above named child; and the undersigned does hereby consent to the minor taking part in activities associated with FBC during the months of January to December, with the full understanding insofar as during activity there is always the risk of injury, illness, loss and possible consequent expense for medical, diagnostic, and curative treatments, and incidental loss and expense, and the undersigned does for him/herself and for and on behalf of the minor assume the risk of such loss, injury, or expense, and does hereby wholly release FBC from any responsibility or liability; and waives claim or causes of action against it or its agents that might arise on account of loss, injury, or expense occasioned by any sort or accident or any other circumstance involving such child, and agrees to hold harmless FBC in event any such claim should arise; and the undersigned agrees to abide by the rules and regulations, supervision and discipline set and applied by FBC and its 1 P a g e **Please complete BOTH sides of this form** P e r m i s s i o n F o r m
GENERAL PERMISSION SLIP & RELEASE OF LIABILITY (Page 2) representatives. I understand that I will be financially responsible for any medical costs incurred in the emergency treatment and/or transportation of me or my child. Should it be necessary for me or my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. I hereby, in consideration of such benefits and other good and valuable consideration received, consent to the above listed participation and release absolutely, forever discharge, hold harmless and covenant not to sue FBC, its employees, volunteers, and affiliates from any and all present or future liability, claims, demands, actions or rights of action, whether asserted by me or a third party arising out of me or my child's participation in event activities (the "Claims"). I agree to indemnify and hold harmless FBC for any such Claims brought by me or a third party from any costs associated with defending or litigating such claims, including but not limited to attorney fees, costs and legal expenses. I hereby release, forever discharge and agree to hold harmless FBC from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the undersigned adult and the child-participant that occur while me or my child is participating in any trip or activity with FBC. Furthermore, I [and on behalf of my child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage, and expenses as a result of participation in recreation and work activities involved therein. The medical consent and liability waiver provisions hereof shall remain in full force throughout the months listed below and in effect until written notice of revocation or withdrawal is received by FBC at its office at 487 Fellowship Rd. Trout, LA (P.O. Box 2438 Jena, LA). It is the responsibility of the parent or guardian to notify the church of any changes in medical information, guardianship, address or phone change in writing to the address listed at the beginning of the form. I give my permission for my son/daughter to attend functions with FBC during the time period of January 1, December 31,. 2 P a g e **Please complete BOTH sides of this form** P e r m i s s i o n F o r m
CONTACT AND MEDICAL INFORMATION Student Name Date Completed Address Birth Date Sex (circle): M F Grade School Parent/guardian names Contact Numbers: Home Work Cell Emergency Contact: Name Relationship to student Daytime Phone Evening Phone Hospital Insurance: Yes No Name of Insurance Company Phone Group Number Policy Number Policy Holder Last 4 digits of Policy Holder s SS# Family Physician Phone Family Dentist Phone Date of last tetanus shot Are all immunizations current? Allergies: Indicate if your child has ever had any of the following: Diabetes Asthma ADD/ADHD Depression/Mental Health Current Medication(s) Medication Instructions (times/dosage) Special Diet Other Important Medical Information **I hereby DO consent or DO NOT consent to the use of blood and/or blood products under the care of a licensed physicians in the case of an emergency. 3 P a g e **Please complete BOTH sides of this form** P e r m i s s i o n F o r m
PERMISSION SLIP FOR USE OF PG-RATED, PG-13, AND R-RATED MOVIES FBC youth ministry goal is to help teenagers have a real-world relationship with God. That means we need to address real-world issues in our youth group, and we need your help to accomplish this. Through discussions that reveal either the gospel s presence or absence in popular culture, we help young people develop an ability to think critically and faithfully about the messages the media presents. In turn, we encourage them to live their faith authentically at school, home, and church, and to engage the Holy Spirit s discernment in their lives. As part of our youth ministry program, we will sometimes be using videos as discussion starters and for entertainment purposes. The movies may include PG-rated, PG-13, and some R-rated movies, such as The Passion of the Christ. R-rated movies with excessive profanity or obscene language or intense sexual situations will not be allowed. R-rated movies will be used only when we believe they offer powerful illustrations about life and/or faith. We will communicate clearly to our young people that the viewing of this movie is not an endorsement of the movie. We will voice this disclaimer as well for any PG or PG-13 movies that contain offensive material. If you understand and approve of our plan to occasionally use videos or video clips from R, PG-13 or PG-rated movies when we believe it s appropriate, please indicate your support by signing below. 4 P a g e **Please complete BOTH sides of this form** P e r m i s s i o n F o r m
MEDIA CONSENT/RELEASE FBC maintains a website on the World Wide Web and also maintains an active Facebook page. Occasionally, photos/videos of church members are posted on the website and Facebook page. We plan to photograph/record youth events that may include you or your child and seek your permission to publish photos of you or your child on our website and in our print publications at our discretion. By completing this section and signing, you are indicating your understanding, support, and approval. I give my consent and permission for the taking of photographs and/or video of me or my child during FBC events and waive and/or assign any and all rights (including copyright) in such media to FBC. FBC, as the sole owners of such media, shall have the exclusive right to control and determine the use, display, performance, reproduction and dissemination of any such photographs and/or videos. I hereby grant permission to Fellowship Baptist Church, Jena, LA, to use the photographs and video tapes on its World Wide Web site, Facebook page or in other official church printed publications without further consideration. I acknowledge the church s right to crop or treat the photograph and video at its discretion. I also acknowledge that the church may choose not to use me or my child s photos and videos at this time, but may do so at its own discretion at a later date. I also understand that once me and my child s image is posted on FBC s website and Facebook page, the image can be downloaded by any computer user anywhere in the world. Therefore, I agree to indemnify and hold harmless from any claims the following: Fellowship Baptist Church, Jena, LA. The Employees and Volunteers of Fellowship Baptist Church, Jena, LA. FBC reserves the right to discontinue use of photos without notice. 5 P a g e **Please complete BOTH sides of this form** P e r m i s s i o n F o r m
I represent and acknowledge that I have completely read and understand this document and all its terms and all matters referred to herein, and I signed voluntarily as my free act and deed, that I have had an ample opportunity to obtain the advice of counsel and that, by signing this document, I understand that I am relinquishing legal rights and remedies that may have otherwise been available to me. I understand that this Waiver and Release shall be construed as broadly and inclusively as is permitted by applicable law and agree that if any portion of this document is held invalid, the remaining shall continue in full force and effect. To the extent the restriction on filing lawsuits is deemed unlawful, I agree to submit any Claims to a Christian conciliation/mediation organization for binding resolution. CAUTION: READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. THIS IS A GENERAL RELEASE AND INDEMNIFICATION OF CLAIMS. Parent/Guardian Signature: Print Name: Date: Notary Information The following is to be completed by the notary witnessing parent/guardian s signature. The State of the County of Before me, a Notary Public, on this day personally appeared known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this day of, A.D.. Notary Public, Signature My commission expires the day of, A.D.. 6 P a g e **Please complete BOTH sides of this form** P e r m i s s i o n F o r m