Overnight/Trip Registration
You can only register others if you are their LEGAL GUARDIAN.
If you are not registering a child, or if you are not the legal parent/guardian,
please click HERE to select a different form.
To make a payment or a deposit, please click HERE.
PLEASE NOTE: Items marked with an * are required fields. If the field does not apply, please enter “N/A” or “none.”
 

Please enter the name of the event for which you are registering.

EVENT NAME:*

If "Other" was selected, please enter name of event:

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Parent/Guardian Name*

Parent/Guardian E-mail*

I am registering myself as a participant in this event as well.* YesNo

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Home Address:*

City:* State:* Zip:*

- Zip code if "Other" was selected:

Parent/Guardian Best Phone #*

Parent/Guardian Secondary Phone #

Emergency Contact Name*

Emergency Contact Phone #*

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CHILD #1 INFORMATION

Child 1's Name*

Child 1's Birthday*

Child 1's Grade*

Allergies*

Medications (please include dosages and times)*

Special Instructions*

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CHILD #2 INFORMATION

Child 2's Name

Child 2's Birthday

Child 2's Grade

Allergies

Medications (please include dosages and times)

Special Instructions

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CHILD #3 INFORMATION

Child 3's Name

Child 3's Birthday

Child 3's Grade

Allergies

Medications (please include dosages and times)

Special Instructions

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CHILD #4 INFORMATION

Child 4's Name

Child 4's Birthday

Child 4's Grade

Allergies

Medications (please include dosages and times)

Special Instructions

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YOUR MEDICAL INSURANCE INFORMATION:

Medical information is required for overnight or out-of-state trips.

Insurance Company:

Group #:

Membership ID #:

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Liberty Baptist Church has permission to photograph my child(ren) and use photos for church related literature.
Yes.No.

ADDITIONAL COMMENTS:

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RELEASE OF LIABILITY
I do hereby release Liberty Baptist Church, and any of its representatives, whether paid staff, or volunteer, from any and all liability related to the transportation of all listed participants via church provided transportation. I further agree to release any and all persons involved jointly with said participants in transportation (i.e. others riding in transportation vehicles) from any and all liability where transportation is concerned.
I understand that drivers in the church transportation program are not necessarily certified as “commercial drivers” as constituted by a “CDL” or commercial driver’s license, however all drivers are pre-screened before assuming the responsibility of transporting others.
In consideration of the opportunity of listed participants in Children’s Ministry or Youth Ministry activities at Liberty Baptist Church, I/we assume all risks and hazards incidental to such participation, and do hereby release, absolve, indemnify, and agree to hold harmless Liberty Baptist Church. I also agree that any of the said persons shall not be held financially responsible for any injury, illness, or death as a direct or indirect result of this activity.
The “Authorization Signature” must be made by the child’s parent or legal guardian if the child is under 18 years.

MEDICAL CONSENT
I grant my authorization and consent for Liberty Baptist Church designated representatives to administer general first aid treatment for any minor injuries or illnesses experienced by listed participants. If the injury or illness is life threatening or in need of emergency treatment, I authorize the designated representative to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the designated representative in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

I/WE THE UNDERSIGNED, HAVE READ THIS RELEASE AND UNDERSTAND ALL ITS TERMS AND EXECUTE IT VOLUNTARILY AND WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE. I/WE UNDERSTAND THAT THERE IS NO MEDICAL INSURANCE PROVIDED BY LIBERTY BAPTIST CHURCH.

ELECTRONIC SIGNATURE AGREEMENT. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

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CHECK the box IF YOU AGREE to the terms and conditions.

My Legal Name - "Authorization Signature":

Date of Agreement:

Please enter the letters you see in the box for verification.
captcha

Form updated 02/22/2017