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Register here: KBA WEEK 1, REd Oak Cabin

GBSM DIGITAL WAIVER

*MUST BE FILLED OUT BY LEGAL PARENT OR GUARDIAN

**THIS RELEASE IS EFFECTIVE FOR THE 2020 CALENDAR YEAR ONLY!**

Name of Student

First Name

Last Name

T Shirt Size

Adult sizes only

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Phone

If they have one

(###)

###

####

Age

Birthday

MM

DD

YYYY

Last Grade Completed

School

Name of the Individual Filling Out This Form

First Name

Last Name

Are You the Student's Primary Emergency Contact?

Parent/Guardian Emergency Contact

If someone other than the person filling out this form!

First Name

Last Name

Relationship to the Student

Emergency Contact Address

Skip this section if the same as above!

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emer. Contact Phone

(###)

###

####

Insurance Company that Covers the Student

Provide as much information as possible

Any Specific Medical Conditions?

Provide as much information as possible. Type "None" if the student has no specific medical conditions

Year of Last Tetanus Shot

Any Past Serious Injuries

Provide as much information as possible. Type "None" if the student has no specific medical conditions

Current Medications

Provide as much information as possible. Type "None" if student has no specific medical conditions

Physical Restrictions, Allergies, Food Specifications, etc...

Provide as much information as possible. Type "None" if the student has no specific medical conditions

Does Your Student Wear Glasses or Contacts?

Specify which one Type "None" if the student has no specific medical conditions

IMPORTANT: READ THIS

If a medical emergency should arise while the above named is participating in any Graceway Baptist Church activity, and I cannot be contacted, I hereby give permission to any sponsor of that activity to select a physician, hospital and/or clinic for his or her care. I also give the physician, hospital and/or clinic, as selected by said sponsor, my permission to hospitalize, treat and order injections to meet the needs of the above named. I will assume responsibility for any and all bills arising from said treatment(s). In consideration of the permission extended to the above named to participate in the activities of Graceway Baptist Church, I hereby release and hold harmless all employees, staff members and sponsors of Graceway Baptist Church of and from any and all manner of action and causes of actions, judgments, executions, debts, claims, and demands of every kind and nature whatsoever which against them I have had or now have of which I or my heirs, executors or administrators have now or may hereafter have by reason of the above-named participation in Graceway Baptist Church activities, as well as any other operations incident thereto. By signing today, I declare that the information provided is accurate, and the terms of the herein release have been completely read, and are fully understood and voluntarily accepted.

Date This Form Was Filled Out

MM

DD

YYYY

Digital Signature

Do you give us your consent to attach a digital signature to this form?

Relationship to Student If Different Than Emer. Contact