Participant Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender *

Male

Female

Home Phone

(###)

###

####

Mobile Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Signature *

I further certify that I am in good health and have no physical or other impediment which would endanger me while participating in this activity. I will not be under the influence of drugs or alcohol, which would impair my ability. I acknowledge and agreed this activity has inherent risks. I have full knowledge of the nature and extent of all the risks associated with this activity. In consideration of my participation in this activity, I agree (on behalf of myself, my heirs, executors, administrators, and assigns) to release, discharge, waive and relinquish Friendship Community Baptist Church (or its officers, agents, employees and volunteers) from any and all liabilities, claims, or actions for personal injury, property damage, or wrongful death which may arise out of my participation. I HAVE CAREFULLY READ BOTH FRONT AND BACK OF THIS AGREEMENT, WAIVER AND RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND FRIENDSHIP COMMUNITY BAPTIST CHURCH AND I SIGN IT OF MY OWN FREE WILL.

First Name

Last Name

Date *

MM

DD

YYYY

Consent of Parent or Guardian *

(To be completed and signed by parent/guardian for participants under 18 years of age). I certify that I am the parent or legal guardian of the above participant and that I am entitled to his or her custody and control and I do hereby give permission for the Child to participate in the above activity. I further certify that the Child is in good health and has no physical or other impediment which would endanger him or her while participating in this activity. I realize that by participating in this program, the Child will be exposed to a risk of injury or death. I understand the dangers incidental to participating in the program and the need for safety precautions, and I have discussed the dangers of the program and the need for safety precautions with the Child. I hereby execute the above Agreement Waiver, and Release on his/her behalf.

First Name

Last Name

Date

MM

DD

YYYY