Release Form
must be completely filled out
 
 
Authorization for Release or Emergency Care Form
 This portion must be completely filled out for your child to be registered.
 
1. Permission is granted for my child to travel with any staff or volunteer of PCBC for Vacation Bible School purposes.
 
2. Permission is granted for the officials, staff, volunteers of Peachtree Corners Baptist Church to administer First Aid, to obtain the services of a Licensed Physician, and to arrange transportation to nearest hospital in case the child named above is seriously ill, injured or requires hospitalization.
 
3. Permission is also granted to the Attending Physicians to render whatever treatment they deem necessary for the child's welfare. The responsibility for all expenses incurred will be assumed by the individuals whose signature appears below.
 
4. I hereby release and discharge the staff of Peachtree Corners Baptist Church and its volunteers from any and all liability in case of accident or any other injury which might occur to my child through administering First Aid or transportation to a medical facility. I hereby release any and all of the above from any liabilities because of any injury or damage
which might occur while in the care of the staff and volunteers.
 
5. I hereby give permission for Peachtree Corners Baptist Church to use any pictures taken at this event for publication.
 
 
Insurance Company
 
Insurance Co. Phone Number
 
Name of Insured      
 
Policy Number         
 
Group Number         
 
Emergency Contact
 
Emergency Phone    
 
By initialing the following you are granting Representatives of Peachtree Corners Baptist Church
 
               Permission to Seek Emergency Care   
 
               Permission to travel for VBS purposes  
 
               Permission to use photographs           
 
Click to Submit 
 
 
Mail or drop-off to the church:
Peachtree Corners Baptist Church
Attention: Kid's Ministry, Marcia Alford
4480 Peachtree Corners Circle
Norcross, Georgia 30092