General Activity - Photo & Video Release printable pdf download

Christ-Centered … Community Focused

Acts 2:47

Potomac Crest Baptist Church

15418 Cardinal Dr

Woodbridge, VA 22193

703-730-7222

2011 - 2012 General Activity & Photo/Video Release

Child’s Name: _________________________________________

Address: ______________________________________________

Parent/Guardian Name: __________________________________

Phone Numbers: HM: _______________Cell: ________________

Is your child currently taking any medicine or treatment?

If yes, explain-_____________________________________

Is your child allergic to anything? __________________________

In the event of an emergency, I hereby give permission to the Potomac Crest sponsor who

is with me/my child or their designee to obtain medical assistance for me/my child. I also

give permission to the licensed physician selected to secure x-rays, routine tests and the

proper treatment(s) for me/my child.

Intending to be legally bound hereby, the undersigned agrees and does hereby release

from liability and to indemnify and hold harmless Potomac Crest Baptist Church and any

of its employees or any person or entity related to the church as regards to any

programmed event my child participates in. This release is for any and all liability for

personal injuries (including death) to self or child and property losses or damage

occasioned by, or in connection with any activity or accommodations for this event. The

undersigned further agrees to abide by all the rules and regulations promulgated by

Potomac Crest Baptist Church.

I give / do not give (circle the appropriate answer) consent to the use of my child’s

video and/or photo image, as well as their comments and/or opinions expressed of our

club. I affirm that I have the legal right to issue such consent.

This release is effective for one (1) year from the date signed below.

Parent/Guardian signature: ___________________________ Date: ______

(It is recommended that you also provide a copy of your insurance card to keep on file with this form.)

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08/03/2011

General Activity - Photo & Video Release