HAMPSTEAD BAPTIST CHURCH - PO Box 95 | 328 Hanover Pike - Hampstead, Maryland 21074
(410) 374-9908 - www.hampsteadbc.org
Page 1 of 2
LIABILITY AND MEDICAL RELEASE FORM
Student’s Name:
LAST FIRST MIDDLE
Student’s Address:
STREET CITY/COUNTY STATE ZIP
Student’s Birthday:
Are you currently taking medicine or treatment? Yes No
If yes, explain
Date of last Tetanus Toxoid Immunization: Month Year
Do you have: List any Allergies:
Sinus Trouble Food:
Hay Fever
Heart Trouble Medications:
Epilepsy
Asthma Other Medical Needs:
Diabetes
Communicable Diseases, Explain:
Family Physician: Phone:
Address:
Insurance Company: ___________________________________________ Policy Number:
(Please attach a photocopy of the FRONT & BACK of your current Insurance Card)
UNITY BAPTIST CHURCH – PO Box 670 - 4951 Mount Sinai Road - Prince George, VA 23875
(804) 458-7440 – UnityBaptist2000@aol.com - www.UnityBaptist.us
Page 2 of 2
SECTION 1: Liability Release and Parental Consent (Photo Consent)
I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which
may hereafter occur to me or my child as a result of participation in HBC Youth Ministry Activities from August 1, 2018 o
August 31, 2019. This release is intended to discharge in advance Hampsted Baptist Church of Hampstead, MD, its
officials, officers, employees, volunteers and agents from liability, even though that liabi
lity may arise out of perceived
negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element
of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed
that this waiver, release and assumption of risk is to be binding on my heirs and assignees.
I give consent for my child, ,to participate in the Youth Ministry of
Hampstead Baptist Church, Hampstead, MD activities and programs from August 1, 2018 to August 31, 2019, and I
execute the above liability release on their behalf.
Parent/Guardian Initials
Photo Release for Minor Children
I DO grant to Hampstead Baptist Church, its representatives and employees the right to take photographs of me, my
property and my children in connection with the above- identified subject. I authorize Hampstead Baptist Church, its assign
and transferees to copyrig ht, use and publish the same in print and/or electronically. I agree that Hampstead Baptist Church
may usesuch photographs of me with or without my name and for any lawful purpose, including for example such purposes
as puposes aspublicity, illust
ration, advertising, a nd Web content.
Parent/Guardian Initials
SECTION 2: Consent for Treatment (CHECK ONE)
□ I DO hereby give my consent to the church-appointed sponsor who is with my child or to any staff person, or their
designee, who is present at the above mentioned event(s) to have the above child treated by emergency medical
personnel, a physician, a dentist or surgeon, in case of sudden illness or injury while participating in any church
sponsored activities. It is understood that Hampstead Baptist Church of Hampstead, MD will provide no medical
insurance and/or payments for such treatment, and that the cost thereof will be at my expense.
□ I DO grant permission for my child to receive Acetaminophen (Tylenol) and/or Ibuprofen (Advil) as needed.
□ I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring
emergency treatment, I wish the church authorities to take no action or to: .
I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its
terms and conditions as completed.
Signature of Parent/Guardian Printed Name of Parent/Guardian Date
Parent/Guardian Address:
Parent/Guardian Phone #1: Phone #2:
Parent/Guardian Email #1: Email #2:
Other Emergency Contact Person:
Phone #1: Phone #2:
HAMPSTEAD BAPTIST CHURCH - PO Box 95 | 328 Hanover Pike - Hampstead, MD 21074
(410) 374-9908 - www.hampsteadbc.org
August 20, 2021 to
December 30, 2022
August 30, 2021 - December 30, 2022
