Slick City Action Park Consent Slick City Consent & Liability Form Participant InformationName First Last Date of Birth* Date Format: MM slash DD slash YYYY Grade (if applicable)Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Medical InformationPlease complete this section with participant's medical information. This includes chaperones and youth.Medical Insurance*YesNoHealth Insurance ProviderPlease put N/A if you do not have health insurance.Policy NumberPlease put N/A if you do not have health insurance.AllergiesMedical ConditionsMedicationsParent/Guardian Information (for minors)Please complete this section only for youth 18 years old and under.Name First Last PhoneEmail Emergency ContactName* First Last Relationship*Phone*Acknowledgment and Release: I, the undersigned, acknowledge that participation in the trip to Slick City Action Park involves inherent risks, including but not limited to physical injury. I hereby release and hold harmless Holman Street Baptist Church, its staff, volunteers, and affiliates from any liability arising from participation in this event. Medical Consent: In the event of an emergency, I authorize Holman Street Baptist Church representatives to obtain medical treatment for the participant named above. I understand that I am responsible for any medical expenses incurred. Transportation Consent: I give permission for the participant to be transported to and from the event by authorized church personnel or volunteers. Photo/Video Release: I grant Holman Street Baptist Church permission to use photographs or videos taken during the event for promotional purposes. Parent/Guardian Signture (if 18 years old or younger)*By typing my full name below, I acknowledge that I have read, understood, and agree to the terms outlined above. I consent to participate (or allow my child to participate) in the trip to Slick City Action Park with Holman Street Baptist Church, and I affirm that this typed name represents my electronic signature.Date* Date Format: MM slash DD slash YYYY Participant Signature*By typing my full name below, I acknowledge that I have read, understood, and agree to the terms outlined above. I consent to participate (or allow my child to participate) in the trip to Slick City Action Park with Holman Street Baptist Church, and I affirm that this typed name represents my electronic signature.Date* Δ
