2-24-19 Sr High Boulderdash Activity
2-24-19 Sr High Boulderdash Activity
Teen's Name  * 
Gender  * 
Grade  * 
Address * 
Guardian's Name  * 
Guardian's Cell Phone Number  * 
Alternate Phone Number
I (we) the undersigned parent(s), or legal guardian, of the child listed above, a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical
diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act or
and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public. It is understood that this
authorization is given in advance of any specific diagnosis, treatment, or hospital care being required and is given to provide authority and power to render care which the
aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that all efforts shall be made to contact the undersigned prior to rendering
treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
This authorization is given pursuant to the provisions of section 25.8 of the Civil Code of California.
Guardian signature for the statement above  * 
List any restrictions (If none, please write "Not Applicable" or "None") * 
Allergies to Drugs and Foods (If none, please write "Not Applicable" or "None")  * 
Family Physician's Name
Physician's Phone Number
Physician's Address
Insurance Company
Policy Number
I hereby grant permission for my child to attend the 2019 Faith Baptist Boulderdash Activity. I give permission for my child to participate in all activities. I hereby give
authority over my son/daughter while under the responsibility of the duly Faith Baptist Church youth workers, counselors, etc., and promise to support them in all matters of direction and
discipline. I acknowledge, that if deemed necessary by church youth workers, that if my son/daughter be sent home for discipline reasons or sickness, I will assume
all financial responsibilities and arrange for his/her trip home. I understand that my child will be traveling by church bus to and from the Boulderdash Activity location. I agree that any controversy or claim
against Faith Baptist Church and Schools, its employees or volunteers, or claim arising during the activity, which cannot be resolved within Faith Baptist Church and Schools, shall be resolved
with the assistance of the Center for Conflict Resolution through mediation or, as a last resort through legally binding arbitration, also by the Center for Conflict Resolution.
I expressly waive my right to file a lawsuit against Faith Baptist Church and Schools, its employees or volunteers, except to enforce a legally binding arbitration decision. I agree to
pay legal fees for Faith Baptist Church and Schools, should they not be found at fault.
You agree that your use of a key pad, mouse, or other device or any similar act/action to (a) select an item, button, or icon herein, or to otherwise provide the church with
information in connection with your completion of this Electronic Authorization Form or (b) make any selection regarding any agreement, acknowledgement, consent terms, disclosures
or conditions in this Electronic Authorization Form, constitutes your acknowledgment that the information provided and/or the selection made, as the case may be, is true and
Guardian signature for the statement above  * 
Please sign the Authorization Form by entering your initials below and by entering your full name and the date in the boxes provided. Your typed name, date, and initials will
together serve as your signature for this Electronic Authorization Form. The electronic signature below and related fields are treated by Faith Baptist Church like a physical
handwritten signature on a paper form as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to
validate your electronic signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any
resulting contract between you and the church. If you do not wish to sign this Electronic Authorization Form, please contact the church office at info@faithbaptist.org.
Guardian signature  * 
Today's date  * 
The Boulderdash Indoor Rock Climbing Waiver must be printed, signed, and brought to the activity. No teenager may participate without without a signed waiver.
This Form can be filled out at the link below, but must be printed and signed by a guardian. https://app.rockgympro.com/waiver/esign/boulderdashclimbing/da215cfd-0d81-4f22-9b7b-91a5cda09096
Link to Boulderdash Website: http://www.boulderdashclimbing.com/sfv/
Your Email Address  * 
Total $
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