Christ-Centered … Community Focused
Potomac Crest Baptist Church
15418 Cardinal Dr
Woodbridge, VA 22193
2011 - 2012 General Activity & Photo/Video Release
Child’s Name: _________________________________________
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.)