Summer in the City Student Mission Week Registration

Student Information

Please submit one form per student.
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Consent and Release Form

Emergency Contact #1

Relationship to Participant
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Emergency Contact #2

Relationship to Participant
 *
 
Insurance Information
I (we) understand that in the event medical treatment is required, every effort will be made to contact me (us). However, if I cannot be reached, I give permission to the Faith Community Bible Church (FCBC) staff or sponsor to secure the services of a licensed physician to provide care necessary, including anesthesia, for my child's well-being.
 
By signing this Permission and Waiver Form, I expressly assume all risks to the child participating in the activities, whether such risks are known or unknown to me at this time. I further release FCBC and its ministers, leaders, employees, volunteers and agents from any claim that my child may have or that I may against them as a result of injury or illness incurred during the course of participation in these activities. I further agree to indemnify and hold harmless the church and its ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.

I hereby authorize FCBC to publish the photographs taken of the registered minor children for use in the FCBC website and for display in the facility. I release FCBC from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children registered and that I have the authority to authorize FCBC to use their photographs. I acknowledge that since participation in publications and websites produced by FCBC is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by FCBC confers no rights of ownership whatsoever. I release FCBC, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.
 
Signed *
clear
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