Shades Students Medical and Liability Release

We appreciate your cooperation in completing the following information as thoroughly as possible.  Please list your child's legal first and last name. 

Be sure to email images of your insurance card (front AND back) to

*Address Line 1
Address Line 2
*Zip/Postal Code
* List all known allergies, if none, type N/A:
* List all current medications, if none, type N/A:
* List two emergency contacts and include first and last names and cell numbers: 
* List Primary Care Physician's name: 

As the parent (or legal guardian), by typing my name and today's date below, certify that my child, named above, has my express permission to participate in all activities, of any nature, sponsored by Shades Mountain Baptist Church (Shades) for the remainder of the church year, August 1, 2021 through July 31, 2022. Knowing that Shades will always try to act responsibly, I fully release Shades, its representatives and staff from all liability of any kind and character from any claim, demand, or cause of action, which might be asserted on my behalf or on behalf of my child against Shades, its representatives or staff.


It is my understanding that the church will attempt to notify me in case of a medical emergency involving my child. If the church cannot reach me, then I authorize the church leaders to seek the care of a doctor or other health-care professional, and I give my permission to the doctor or other health-care professional to provide the medical services he or she may deem necessary, including but not limited to emergency surgery, or x-rays. I understand that I will be responsible for any and all medical expenses. I will notify church leaders of any health consideration that would prevent or limit my child’s participation in any activity. I also give my permission for the church leaders to restrict my child from participating in any activity in which they, in good faith, believe there is some concern for the physical well-being of my child. Should it be necessary for my child to be sent home for medical reasons, disciplinary reasons, or otherwise, I hereby assume all costs.


By signing (typing name below) this waiver and release, the parent or guardian agrees to assume and accept all risks and hazards inherent in all church-related social activities. The parent or guardian understands and acknowledges that he or she is signing for the minor listed on this form and that the signature is for both a medical and liability release. Unless I indicate otherwise below, I authorize Shades Mountain Baptist Church to use in a reasonable fashion, in its sole discretion, my child’s image in publications, videos, websites, or other forms of media. Please check the box if applicable: 

* To sign, type your full name and today's date in the box below: