Emergency Contact 1 Name (First & Last)
Emergency Contact 1 Phone
Emergency Contact 1 Relationship
Emergency Contact 2 Name (First & Last)
Emergency Contact 2 Phone
Emergency Contact 2 Relationship
Allergies (LEAVE BLANK IF NONE)
Medical Situation (LEAVE BLANK IF NONE)
Photo ReleaseI give permission to Birmingham and Berkley First United Methodist Church to photograph and video record participants at Church activities. I give permission to copyright, use, and publish the photographs and video for any lawful purpose, including newspaper articles, church publications, and the church website.
Liability WaiverI acknowledge that participation in all activities at Birmingham and Berkley First United Methodist Church involve risk to the Participant (and to Participant’s parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in such activities, the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The Participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the Participant that is authorized by Birmingham and Berkley First or its agents, employees, volunteers, or any other representatives. Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless Birmingham and Berkley First for any injury arising directly or indirectly out of the activity or transportation to and from the activity, whether such injury arises out of the negligence of Birmingham and Berkley First, the Participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and Birmingham and Berkley First cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.