Youth/Chaperone Participant Form This form is to be filled out by/for every participant. "*" indicates required fields Step 1 of 6 16% HiddenChurch Name*Select your church groupEvent*Please select the event for which you ar filling out this form.EventMission MadnessChildren's Ministry Retreat I am filling this form out for Myself Someone Else Your Name* First Last Phone*Relation to Participant* Participant InformationParticipant is a* Student Chaperone Other Participant Name* First Last Gender*MaleFemaleOtherDate of Birth* MM slash DD slash YYYY AgeGrade in School*6789101112Your Address Street Address Address Line 2 City ZIP Code Phone Emergency Contact InformationName* First Last Phone*Relation* Optional Second ContactName First Last PhoneRelation Medical InformationInsurance Company Group Number Policy Number Physicians Name Physicians PhoneAllergiesMedications Authorization for Treatment & ReleaseAuthorization for Treatment & Release*I, the undersigned, do for myself (or for and on behalf of my child under 18 years of age) give permission for an attending physician or hospital to administer medical care if deemed necessary by a physician. I, the undersigned, do for myself (or for and on behalf of my child under 18 years of age) hereby release from all claims and forever hold harmless the director, employees, volunteers, and agents of the Cooperative Baptist Fellowship of Virginia, from any and all claims and demands for personal injury, sickness, and death, as well as property damage and expense, of any nature incurred by myself (or my child under 18 years of age). I assume personal responsibility for any loss of property incurred by myself (or my child under 18 years of age) at the event of theft or otherwise. I also assume personal responsibility for all medical bills (for myself or a child under 18 years of age). Further, should it be necessary for me or my child to return home due to disciplinary action, for medical reasons, or otherwise, I hereby assume responsibility for all transportation costs. I further understand that photographs, audio recordings, and video recordings may be created during the event and I give permission to the Cooperative Baptist Fellowship of Virginia to use any or all recordings of me or my child in publications, videos, website design, or other media expressions. I agree to the Authorization for Treatment & Release policy.Photo Release*I grant CBFVA permission to use photographs and/or videos of my child participating in scheduled, approved activities for promotional purposes. CBFVA will never release last names of minors in print or web publications. Yes No Δ
