The undersigned hereby gives permission for our (my) aforementioned child/children to ride the bus or van to and from activities sponsored by the Lewisport Baptist Church and to participate in all children’s activities during the 2018-2019 school year (July 1, 2018-June 30, 2019).
We (I) authorize an adult, in whose care the minor has been entrusted, to transfer my child to the emergency room if a parent or emergency number cannot be contacted: to consent to an X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The under signed shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our (my) child to return home due to medical reasons, the undersigned shall assume transportation costs.
The undersigned does also give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Lewisport Baptist Church.
I also give permission for Lewisport Baptist Church to use any photographs or videos taken of my child in, but is not limited to: newspaper, web pages, social media, television, etc.
Username or Email
Username or E-mail:
Confirm new password
Hint: The password should be at least seven characters long. To make it stronger, use upper and lower case letters, numbers and symbols like ! " ? $ % ^ & ).
Display name publicly as
Your custom content goes here.