Forms

Authentic Trip Release
Participant Name (*)
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Address (*)
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City (*)
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State (*)
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Zip Code (*)
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Participant Email (*)
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Enter phone number with no dashes or spaces (i.e. 5025551234).
Phone (*)
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Age (*)
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Birthdate (*)
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Day (*)
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Year (*)
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Gender
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Insurance Carrier (*)
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Insurance Policy Number (*)
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Physicians Name (*)
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Physicians Phone (*)
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Allergies (*)
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Chronic Illnesses (*)
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Medical or Other Information We May Need to Know (*)
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Drugs Currently being taken (*)
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Is the Participant Subject to Motion Sickness
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Please list below what type of drug or its generic equivalent the participant can take.
Which Drug For Motion Sickness (*)
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Which Drug For Fever (*)
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Which Drug For Headache (*)
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Which Drug For Flu Like Symptoms (*)
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By clicking yes below I grant permission for Crestwood Baptist Church to videotape or photograph my child or young person during church events or normal activities. I understand these photos may be used as church promotional materials.
Photo and Video Permission Granted (*)
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Emergency Contact (*)
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Alternate Emergency Contact (*)
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Enter phone number with no dashes or spaces (i.e.5025551234)
Emergency Contact Phone (*)
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Alternate Emergency Contact Phone (*)
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RELEASE, HOLD HARMLESS AND INDEMNITY I, the undersigned, do hereby agree and give my consent to participating in the programs and activities at Crestwood Baptist Church. I, on my own behalf acknowledge that participating in the programs and activities involve certain risks and that injuries, death, or other harm (including damage to my property) could occur("Injuries"). By participating I, on my own behalf hereby assume full responsibility for the risk of Injuries, whether caused by negligence or otherwise. I, on my own behalf and our heirs, successors, assigns, executors and administrators, hereby RELEASE AND HOLD HARMLESS AND AGREE TO INDEMNIFY Crestwood Baptist Church of Crestwood, Kentucky, Inc. and its staff, volunteer leaders, members, employees, deacons, council members, Ministry and Church Leadership (hereinafter collectively referred to as "CBC") from and against any and all liability, claims, damages, causes of action, loss, costs and expenses (including, without limitation, attorney's fees) for Injuries arising out of or connected with the Programs and Activities, including traveling to and from the Programs and Activities.
MEDICAL CONSENT AND AUTHORIZATION If, while participating in the Programs and Activities, I require emergency medical treatment, I hereby give my consent for any emergency medical care to be rendered to myself as may be deemed necessary by any duly licensed physician or dentist. I hereby give my permission to CBC to obtain the emergency medical treatment at any hospital, clinic or other health careprovider as may be deemed appropriate. In these circumstances, I hereby request and authorize any duly licensed physicians, dentists and staff, or other licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of myself, including but not limited to medical transport, hospital tests, injections, anesthesia, surgery and administration of prescription drugs. I assume full responsibility for all medical expenses incurred as a result as a result of such emergency treatment.
Signature (*)
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By checking that I agree with the above statements I acknowledge that this acts as my electronic signature.
To verify the validity of this form, someone from collegiate ministries will be contacting you about the information listed above.
  
(*) denotes required field.