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Medical History and Release of Liability Form

Albuquerque's First Baptist Church

TODAY'S DATE:April 24, 2024

Release of Liability

I, an individual, or as parent or legal guardian of the minor stated below, state my desire to participate (or for my child to participate) in certain activities being offered by or through Albuquerque's First Baptist Church of Albuquerque, New Mexico, the corporate structure, its officers, directors, employees, agents, contractors, and volunteers (collectively referred to as the "Church") and in consideration for being allowed to participate, state and agree as follows:

I warrant that I possess all the rights, power, and privileges on behalf of myself or as a parent or legal guardian necessary to execute this document with binding legal effect. I certify and affirm that I have been completely and thoroughly informed that by attending the activities of the Church, I (my child) will participate in certain activities which carry with them a degree of risk and danger.

Examples of risky and dangerous activities include, but are not limited to:

Physical activities, both indoors and outdoors;
Sports, both informal and organized;
Use of recreational equipment including a Rock Wall;
Field trips; which may include travel by automobile;
Activities around water, including swimming and/or boating;
Hiking and/or Camping; and
Motocross and motorcycle riding; and Rock Climbing indoor on a wall or outdoor on a wall or rock face.

I acknowledge and understand that the Church may offer other activities not listed above that present similar risks and dangers to me (my child). I understand that these activities, listed and not listed, may be undertaken on or off Church property. I understand that
injuries resulting from participating in these activities, listed and not listed, could range from minor aches, bruises and cuts, illness or disease, physical or mental damage and to serious, permanent and disabling injuries, and even in death. I consent to my (my child's) participation in these activities. I acknowledge and understand that this AUTHORIZATION, CONSENT AND RELEASE has the same force and effect regardless of whether the activities engaged in are free or if a fee is charged.

Further, I personally assume, on my (my child's) behalf, all risk in connection with said activities for any harm, injury or damages that may befall me (my child) as a result of participation in the activities, whether foreseen or unforeseen, and I still wish to proceed (allow my child to proceed) with the activities. As a matter of fact, I am familiar with the nature, degree, and type of risks associated with these activities and do not need them explained to me.

In consideration of me (my child) being allowed to participate in these activities and to use the Church's equipment, facilities, staff or volunteers or hired contractors, on behalf of my child, I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless the Church, including the corporate structure, officers, directors, employees, agents, contractors, and volunteers, from any and all claims, demands, or causes of action, which are in any way connected with my (my child's) participation in these activities or use of the Church's equipment, facilities or personnel.

In cases of emergency, I further consent to the examination or treatment of my child by a physician duly licensed to practice medicine in the jurisdiction where the emergency occurs or any health care professional duly licensed to provide health care services in the

state where the emergency occurs for medical care and services deemed necessary by the Church, its agents, servants, and employees. I understand and agree that the Church is not under a legal duty or requirement to render aid or medical treatment but will use its best judgment as to when to render aid or summon medical care. I give permission to the doctor or health care professional to provide any and all medical care they deem, in their professional opinion, to be necessary to maintain the health, safety, and life of me (my child). I agree to pay for any and all medical expenses incurred as a result of the use of this consent.

I understand that it is my obligation to inform an authorized representative of the Church of any and all health considerations or medical conditions that would restrict my (my child's) participation in any and all activities while engaged in the activities. I (my child) shall not participate in the activities if I (my child) am/is not presently healthy or alert enough to, in my judgment, to do so. Should the need for medical attention arise for my child and I am not present, the Church will attempt to contact me as soon as practicable under the circumstances.

While engaged in these activities, I further authorize the Church to take photos or videos capturing my (my child's) name, voice, and likeness and to use such materials for such purposes as the Church deems useful for its purposes.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my (my child's) participation in these activities, I may be found by a court of law to have waived my right to maintain a lawsuit against the Church on the basis of any claim from which I have released them herein.

I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. I have fully informed myself of the contents of this AUTHORIZATION, CONSENT AND RELEASE by reading it before I signed it. This document will be valid for one year of date of signature.

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent/Guardian Information

First and Last Name *

Phone Numbers:


Phone Number (Home)

Phone Number (Work)

Phone Number (Mobile) *

Address:


Street Address:

City:

State:

Zip Code:
Emergency Contact Information:

If the parent/guardian cannot be contacted, please notify:


Name: *

Relationship to Minor:

Phone #1: *

Phone #2:
Security Information:
Is there anyone specifically not authorized to pick up your child?*
No
Yes

If so, who?
Medical Information

Minor's Physician:

Phone:

Date of last Tetanus Shot:

Allergies: (If none, write none)
Chronic/ Reoccurring Conditions: (Please check all that apply)
Asthma/Respiratory Problems
Seizure Disorder
Diabetes
Fainting
Headaches
Heart Disease
Kidney Disease
Nosebleeds
Other

Explanation of any of the aforementioned conditions:

Has your child had any previous operations or serious illnesses? If so, please explain and give dates.
Can your child swim?*
No
Yes

If No, explain the level of experience they have.
Does the student have any physical problems that would hinder him/her from entering into full program activity?*
No
Yes

If yes, what?:
Medical Release

Parent/Guardian Statement: I authorize the adult in charge to consent to medical treatment for my child, when I cannot be contacted.  I understand that every effort will be made to contact me before the action is taken.  I assume financial responsibility for emergency care if such care is not covered by the church's insurance.

I Authorize
I Do No Authorize
Media Release
I give permission for Albuquerque's First Baptist Church the right to use video or still photography of my student in any appropriate publicity or promotion.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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