Grace Baptist Church of Millersville is not responsible for the loss or theft of personal belongings.
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Misconduct may result in transportation home from an activity at parent’s expense. A student dismissed for a disciplinary reason will not receive a refund of the activity fee.
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I understand and authorize that my child’s image maybe photographed or filmed and used in video presentations, printed publications, and the Grace Baptist Church of Millersville website.
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I hereby take the following action for my child, myself, my executors, administrators, heir, next of kin, successors, and assigns: A) I waive, release, and discharge from any and all claims or liabilities for death or personal injury damages of any kind, which arise out of or relate to my child’s participation in Grace Baptist Church of Millersville’s student ministry activities, the following person, or entities: Grace Baptist Church of Millersville, it’s pastors, employees, and volunteers any of the above. B) I agree not to sue any of the persons or entities mentioned above for any of the claims of liabilities that I have waived, released, or discharged herein except in the case of gross negligence on the part of Grace Baptist Church of Millersville, staff, and volunteers and: C) I indemnify and hold harmless the person or entities mentioned above from any claims made or liabilities assessed against them as a result of my child’s actions. I hereby assume the risk of my child participating in all Grace Baptist Church of Millersville student ministry activities.
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I understand that my personal auto insurance will be responsible for my medical bills in the event of an accident involving a privately owned vehicle or a church rented vehicle being used for the Grace Baptist Church of Millersville. I agree not to hold the owners or renters of such vehicles liable for damages, losses, diseases, or injuries incurred.
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The parent or natural guardian or legal guardian of the student hereby executes this document for and on behalf of the minor name herein. I agree and hold hamlets the person or entities mentioned above for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Waiver and Release.
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I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care facility to treat the minor named herein for the purpose of attempting to treat or relieve any injury received by said minor. I authorize any such medical provider to perform all procedures deemed advisable. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk for and on behalf of myself and said minor. I understand that attempts will be made to contact me in the most expeditious way possible. Permission is also granted to Grace Baptist Church of Millersville representative to provide the needed emergency treatment to the student prior to his admission to a medical facility.
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I give my permission to the staff to administer Tylenol/Acetaminophen, Ibuprofen, Benadryl, Diphenhydramine, or even over the counter antacids as needed.
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Child's Name(s)
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Guardian's Name
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First Name
Last Name
Parent(s)/Guardian Phone
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(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Allergies
Insurance Company/Policy Number
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Medical Doctor/Phone Number
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