I, the undersigned parent/guardian of _________________________________________________, a minor,
do covenant to hold harmless Calvary Baptist Church, its staff, and adult volunteers from any and all actions,
causes of actions, claims, demands, damages, costs, loss of services, expense and compensation, on account of ,
or in any way growing out of, any and all known ad unknown personal injuries and property damage which may
result from riding to or from Calvary Baptist Church or one of its scheduled activities on church provided
transportation; or through participation in programs offered by Calvary Baptist Church on its premises.

Further, I do hereby authorize adult workers with Calvary Baptist Church to consent to any examination, x-ray,
anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision
of any physician or surgeon licensed 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.

Further, as parent/guardian of the minor named above, I do hereby expressly consent that my son/daughter may
receive emergency medical treatment from any physician, hospital, or other medical center without the necessity
of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for
rendering such services.

(Please print the following information)

Please list any allergies (food or otherwise) that your child may have and any medications for such allergies:

________________________________________________________________________________

Insurance Company/Group ___________________________________________________________

Policy Number _____________________________________________________________________

Name of Participant _________________________________________________________________

Parent or Guardian __________________________________________________________________

Address __________________________________________________________________________

City ________________________________________ State ____________ Zip _________________

Daytime Phone ________________________________ Evening Phone ________________________

Signature of Parent/Guardian __________________________________________________________

My signature confirms that I hereby give witness to the proper completion of this form by the minor's

parent/guardian.

Signature of Witness or Notary ________________________________________________________