MSM Late Night Registration Students Name: Age:
Grade:
School:
Mother’s Name: Father’s Name: Number to contact in case of emergency: Who will we be contacting at this number? Are there any medical conditions or injuries we should be aware of? If yes, please explain: ________________________________________________________ ________________________________________________________ Medical Insurance Provider: Policy #: Contact Number for above provider:
The cost is $50 per student and the money and paperwork MUST be in by November 13th. (Make checks payable to Second Cape May Baptist Church.) Eligible for Half-off? Check the box below if you are.
□ My son/daughter is eligible for the discounted price! My payment of $25 is included. As you are aware, there are potential dangers associated with the posting of personally identifiable information on a web site since global access to the internet does not allow us to control who may access such information. These dangers have always existed; however, we as a Church do want to celebrate your child’s involvement in our program. The law requires that we ask for your permission to use information about your child. Pursuant to law, we will not and cannot release any personally identifiable information regarding your child without prior written consent from you as a parent or guardian. We would like to post pictures and/or videos on our church’s website (www.secondcapemaybaptist.com) and also on our youth group’s Facebook page. Please check one of the options below. If you have any comments or further instructions, please include them on the space below. I give my permission to allow the church to post pictures /video of my child. I do not give my permission to allow the church to post pictures of my son/daughter.
Please Read and Sign the back of this document as well.
Behavior Notice: Should my child violate any of the rules listed below, I expect to be asked to travel to our event location (locations vary) to withdraw my child from the group and return them home. If requested, I will immediately comply with such a request. I understand that any and all inconveniences, hardships, financial and other costs incurred as a result of such action requested by the group leader are to be borne directly upon me. Neither the church, nor trip staff will bear any of the financial cost. In addition to all other possible reasons for dismissal from the trip, for each of the following violation, A Zero Tolerance is the standard. I will be immediately notified and will comply with the request to travel and pick up my child from the trip if he/she violates any of the following rules: 1. Failure to adhere to policies of Second Cape May Baptist Church AT ALL TIMES while under supervision of any trip leader. 2. Possession of, smoking, or other use of tobacco products. 3. Possession of or use of alcohol or any type of drugs. 4. Possession of any kind of pornographic material. 5. Any behavior that we deem a threat to the safety of another member of the group, a staff leader, or any other group member with whom the student has come in contact with. 6. Any attempt to willfully damage any property of another group member or staff member.
Waiver of Liability: My son/daughter has had a physical exam within the last two years. As such, I judge him/her to be physically fit to participate in the activities. In the event that my child is injured or requires immediate and/or emergency care and I cannot be contacted, I authorize Pastor Jeff Kammerer to act for me according to his best judgment (including treatment and/or transportation to medical facilities). I also authorize area medical personnel to act on my behalf in the event of an emergency and I cannot be contacted. (We will ALWAYS attempt to contact you first and will continue to do so if needed.) Furthermore, I understand that participation in youth events inherently carry risk of physical injury and even death. I, my child’s heirs, our legal representatives, and other related persons furthermore agree to absolve the Second Cape May Baptist Church, its administration, employees, group leaders and other staff from any liability resulting from an injury or death incurred while participating as a group member in the various activities of our Event. I also agree to absolve from liability any other organizations including, but not limited to (FunPlex and Pop Shop) upon whose facilities or property my son/daughter may travel, or otherwise be involved in scheduled or optional recreational or other event activities. I also absolve Second Cape May Baptist Church organization’s employees and the designated group leaders, and other staff from any liability resulting from injury from, damage to - or damage caused bymy child’s use of any equipment found during our retreat. By signing below you acknowledge: □ Your son/daughter is physically able to participate in our Late Night Event. □ Your permission to allow your son/daughter to attend our retreat and be under our care. □ All the above information is accurate and current. Mother’s Name
Signature
Date
Father’s Name
Signature
Date