2019 Life Changers Waiver Form
Please print name that is on Driver’s License or other valid form of ID (Please print name in box).
Please Initial each _____line for Medical release, Liability, and Photo Release.
I hereby authorize Northside Baptist Church to obtain medical treatment for the above-mentioned person as a result of accident or injury while participating in Life Changers activities. This is to include any emergency first aid or medical care by any physician, hospital or attendant, which is deemed necessary by said physician, hospital or attendant as a result of involvement in Life Changers activities.
I hereby give my permission to the physician selected by the director to secure proper treatment, which may include hospitalization, anesthesia, surgery, or injections of medication for myself.
I do assume all costs for necessary medical treatment as needed and allowed in this authorization form.
_____Liability Waiver: I, the undersigned, hereby acknowledge that I willingly assume all risk of injury while participating in the Life Changers program and hereby agree to hold Northside Baptist Church of Valdosta, Georgia, Inc., it’s agents, successors, and assigns, including, but not limited to any owner(s) other than Northside Baptist Church of Valdosta, Georgia, Inc., of facilities where Life Changers program activities occur (NBC & VLPRA), harmless for any and all injuries that I may incur while participating in the Life Changers program.
_____PHOTO RELEASE: This document also serves as a release for me to appear in photographs and/or videotapes while participating in the above stated sports league for the purposes of publicity, staff training, and/or promotion.
Must sign in front of Notary (We can notarize all forms at NBC; either in the church office or on the nights of evaluations)
Signature of Player:________________________ Date________
Notary Signature and seal ____________________ Date________