Backyard Bible Registration for Youth

Child's Name*

First Last

Child's Age*

Guardian Name*

First Last

Emergency Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

My child will attend the following dates:*

Tuesday, June 18
Tuesday, July 2
Tuesday, July 9
Tuesday, July 23

Please select one:*

I intend to attend Backyard Bible with my child.
I do not intend to attend Backyard Bible with my child.

All Known Allergies (food, bee stings, medications, etc), Medical Info, Food Needs, Concerns:

Consent and Waiver*

I, as legal parent, guardian, or adult acting in loco parentis of or for the above named minor, grant to Ormond Beach Presbyterian Church (“OBPC”) and its representatives and employees the right to take photographs of my minor child. I authorize OBPC, its assigns and transferees to copyright, use, and publish said photographs of my minor children in print and/or electronically for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. It is OBPC’s policy to never identify children by name in public photographs. In addition, in consideration for allowing my child/ren to participate in these activities I consent to my e-mail address being added to a “upcoming events” e-mail list and thereby consent to receiving e-mails about upcoming church events, understanding that at any time, if I prefer to no longer receive such e-mails, I may request, in writing, via e-mail, that my e-mail address be removed from the mailing list. Furthermore, I, as legal parent, guardian or adult acting in loco parentis, of or for the below-named minors, hereby give permission for my child/ren to participate in Backyard Bible at the Beach Picnic at the beach, including, but not limited to participating in the water activities at the beach. I covenant and agree that I will be responsible for my child or children’s well-being during any water activities, whatever water activities I permit my child/children to participate in, including but not limited to swimming, surﬁng, paddle boarding, kayaking or other water activities. I understand that there are numerous risks associated with participation in any activities including, but not limited to intentional or unintentional acts or events arising from circumstances or individuals over which OBPC has only limited control or no control whatsoever. In consideration for the privilege of allowing my child/ren participate in the above described activities, I agree to release, hold harmless, defend and indemnify OBPC, its ofﬁcers, agents, employees and volunteers, from any liability or responsibility for bodily injury, damage or illness to my child arising out of participating in any activity which may be directly or indirectly sponsored by the church. I agree to indemnify and hold harmless OBPC, its ofﬁcers, agents, employees, or volunteers with respect to any claim asserted by or on behalf of my child/ren as a result of bodily injury, illness or damage. Further, I expressly agree, on behalf of myself, the below-named minor child/ren, and anyone else on behalf of said minor child/ren, that no one individually or on behalf of the below-named children will hold any or all of the adult volunteers, jointly or individually or otherwise, or OBPC, its ofﬁcers or leaders responsible or liable for any accident, incident or injury that occurs at, around, or relating to this event.

Signature*

First Last

Date*

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