FELLOWSHIP REFORMED CHURCH
Media Release Form (Please Check One):
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I CONSENT to the use of photographs, video recordings, audio recordings, and other media containing the participant's image, likeness, voice, and/or name by Fellowship Reformed Church (FRC) for ministry, educational, promotional, and communication purposes, including but not limited to printed materials, websites, social media platforms, presentations, and other publications. I understand that these materials may be used without compensation and that I waive any right to inspect or approve the finished product in which they may appear.
I DO NOT CONSENT to the use of photographs, video recordings, audio recordings, or other media containing the participant's image, likeness, voice, and/or name by FRC. I understand that reasonable efforts will be made to honor this request; however, I acknowledge that complete exclusion from incidental appearances in group photos, videos, or public event recordings cannot be guaranteed.
Consent Form (Please Sign Below):
I understand that FRC maintains strict guidelines regarding the types of electronic communication permitted between minors and staff/volunteers. These communications are intended to be public in nature whenever possible. With this consent, staff and volunteers may maintain student e-mails and phone numbers for the purposes of event-oriented communications and/or mentoring relationships. Parents/guardians have the right to review these communications if requested. I also agree that I have read or have waived my right to read the Summarized Child Protection Policy.
I hereby release and agree to fully and unconditionally protect, indemnify, and defend FRC and their respective officers, agents, and employees, (collectively, "Indemnitees") and hold each Indemnitee harmless from and against any and all costs, expenses, attorney's fees, claims damages, demands, suits, judgments, losses, or liability for injuries to property, injuries to persons (including child) and from any other costs, expenses, attorney fees, claims, suits, judgments, losses, or liabilities of any and every nature whatsoever arising in any manner, directly or indirectly, out of, in connection with, in the course of, or incidental to the use or publication of any photographs, videos, or other images of child(ren), regardless of cause or of the joint, comparative, or concurrent negligence of the Indemnitees.
Participant's Name
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Parent/Guardian Telephone
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Format: (000) 000-0000.
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PARENTAL CONSENT / RELEASE FORM
Age
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Birth date
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Month
-
Day
Year
Date
Grade
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Cell Phone
Format: (000) 000-0000.
City
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Zip
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Church
School
Parent/Guardian Information:
Parent/Guardian Information:
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Rows
Name
Cell Phone (xxx)xxx-xxxx
Email
Work Phone (xxx)xxx-xxxx
1
2
Emergency Contact Name (other than Parents)
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Emergency Contact Phone
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Format: (000) 000-0000.
The undersigned grants permission for their child, ____________________, to attend and participate in activities sponsored by or involving Fellowship Reformed Church ("FRC"), including transportation in vehicles designated by FRC leaders. In consideration of FRC permitting participation, the undersigned, on behalf of themselves, the child, and any other parent or guardian, releases and holds harmless FRC and its officers, directors, employees, agents, and volunteers from any claims, liabilities, damages, costs, or expenses arising from or related to the child's participation in such activities, including injuries, property damage, or the acts or omissions of other participants or individuals. The undersigned further agrees to indemnify and hold harmless FRC and its representatives from any loss or liability related to the child's participation.
The undersigned authorizes FRC leaders to obtain necessary medical, dental, surgical, hospital, or emergency care for the child. In a life-threatening emergency, FRC will call 911 immediately and then notify the parent(s)/ guardian(s) as soon as reasonably possible. In other situations where medical treatment may be required, FRC will attempt to contact the parent(s)/guardian(s) before treatment is provided whenever reasonably possible. The undersigned accepts responsibility for all medical expenses incurred on behalf of the child and for any transportation costs if the child must return home early for medical or other reasons. This authorization shall remain in effect for four (4) years from the date signed unless revoked earlier in writing.
Hospital Insurance
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Yes
No
Insurance Company
Policy Number
Policy Holder
Group Number
Primary Care Doctor
Doctor Phone
Format: (000) 000-0000.
Allergies and Reactions:
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Other Special Medical Problems we should be aware of:
Signature of Parent/Guardian
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