Please List any Adults approved to pickup your child.
I, the legal parent/guardian of the child listed on this form, hereby authorize and
consent to the use of images or videos of my child listed above, with or without their
name, by Denman Avenue Baptist Church of Lufkin, Texas for the purposes including
but not limited to: promotional materials, printed publications, internet posts including
social media, television, and other media sources.
I do this with full knowledge and consent and waive all claims for compensation for use
or for damages. I release Denman Avenue Baptist Church, it’s officers, trustees, employees,
and agents from liability for any claims by me or any third party in connection with
the use of the image of my child listed above.
Being the parent or legal guardian of the child listed on this form,
I do consent to any x-ray,
anesthetic, medical, surgical, or dental diagnosis or treatment that may be deemed necessary
for my minor child. Further, I understand that all efforts will be made to contact me prior to
treatment. In the event I cannot be reached in an emergency, I give permission to the activity
leader to make the decisions necessary for treatment. Should there be no activity leader available,
I give permission to the attending physician to treat my minor child. I further understand
that the doctors, dentists, and other providers attending to my child will take all reasonable
safety precautions during their care.
Further, as parent or legal guardian, I am responsible for the health care decisions of my minor
child and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital
care or treatment that is given to my child. Any policy of the organization sponsoring this
event will be used as the secondary coverage.
Minor’s date
