Event Registration

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FSM Summer Beach Camp 2024 on Monday, June 24, 2024 @ 2:00 PM

Please follow this link to the FSM - Camp Scholarship Fund (it will open a new window) if you would like to donate to a scholarship fund for those students who may need assistance to attend.
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Please fill out the additional registration and release information below. Thank you!

Please list up to 3 friends you would like to room with. We will do our best to accommodate requests but cannot guarantee rooming assignments
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2:
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*Gender:
*Student Age:
*Last Grade Completed (2023/24 School Year):
*T-Shirt Size:
PARENTAL PERMISSION AND RELEASE FORM

You have requested that  the above name child (Attendee) be permitted to participate in a specific event being offered by the First Baptist Church of Plant City (the “Church”). Specifically, you wish for the Child to attend and participate in the above referenced event. Your signature below represents your acknowledgment that your Child has your full permission to participate in the event, and that the event may involve a risk of harm. You understand that there is a chance the Child may be seriously injured (or even killed) as a result of his or her participation in (or his or her transportation to) such activities. This risk includes the risk of infection (whether with COVID-19 or any other communicable disease).
YOU HAVE THE RIGHT TO REFUSE TO SIGN AND SUBMIT THIS FORM. LIKEWISE, THE CHURCH HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN AND SUBMIT THIS FORM.
*Parent or Guardian Name:
*Parent or Guardian Address:
*Parent Email:
*Parent Contact Phone:
If not available in an emergency during the event, please notify:
*Name Of Emergency Contact:
*Phone Number of Emergency Contact:
*Relationship to Attendee:
*Insurance Company Name/Address:
*Insurance Company Phone Number:
*Policy #:
*Group #:
*Insured's Name:
Please list any past medical conditions we would need to be aware of including but not limited to: asthma, diabetes, eyes, sinusitis, heart trouble, ears, bronchitis, dizziness, nosebleed, kidney trouble, stomach upset, hay fever, etc.
Allergies:
Food:
Penicillin or Other Drugs:
Insect Stings/Bites:
Other:
*Is the student currently taking prescription medication?:
If YES, list all:
Permission to administer:
*Aspirin:
*Ibuprofen:
*Tylenol:
*Is there any other medical information of which we should be made aware?:
If YES, please describe:
CONSENT AND RELEASE

In exchange for my minor child being allowed to participate in the event listed above, I, on behalf of my minor child, myself, my heirs, executors and administrators, hereby waive and release any and all rights and claims for damages I and/or my minor child may have against the Church or against its agents, employees, volunteers and contractors from any and all claims, damages or actions of any nature whatsoever, as a result of my child’s participation in the event listed above (even if the negligence is that of the Church or its agents, employees, volunteers, or contractors). I, on my own behalf and that of the Child, hereby release the above parties from any and all demands, claims or actions, based on personal injury—regardless of the severity—including ones arising from the negligence of the Church or any of its employees, representatives or agents. I understand and agree that, it is possible that one or more pictures and/or video & audio recording of the Child may be taken and/or made. I expressly grant the Church exclusive license to utilize such image or recording in its promotional and educational materials. Further, I waive and release any and all rights and/or claims for damages I may have against the Church (or against its agents, employees, volunteers and contractors) from any and all claims, damages or actions of any nature whatsoever as a result of such use or display (including, but not limited to, claims pursuant to Chapter 540, Florida Statutes).

I, on behalf of myself and the Child, recognize and agree that the event may be physically, emotionally and/or spiritually beneficial to the Child. I further recognize and agree that the event involves inherent and unavoidable risks. Further, I understand that certain dangers and risks cannot be eliminated, no matter how diligent or proactive the Church or any of its employees or agents may be. This specifically includes, but is not limited to, infection with COVID-19 and/or any ancillary impacts of contracting the virus. The undersigned acknowledges that by signing this form, I am waiving (giving up) any right I (or the Child) may have to bring suit against the Church or any of its employees or volunteers arising out of any personal injury, death or other loss that results from the Child’s participation the event. Should there arise any dispute relating to this Release – or the event to which it relates – such dispute shall be submitted to mediation and, if necessary, binding arbitration (such arbitration being conducted in accordance with the rules for arbitration used by Peacemakers Ministries).

You understand that this document is a full and complete release of all claims for personal or bodily injury and property damage which the Child might sustain, regardless of the specific cause thereof. You further understand and agree that in the event of: 1) any personal or bodily injury to the Child, or 2) property damage, you (either on your own behalf or that of the Child) will not seek any type of recovery from, or bring any type of action whatsoever against, the Church or its pastors, officers, directors, employees, or agents.
*BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ THIS FORM COMPLETELY AND CAREFULLY.
*PARENT/LEGAL GUARDIAN NAME:
*Date: