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
Click Here to download
Emergency Contact Form.
Mail or drop-off to the church:
Peachtree Corners Baptist Church
Attention: Kid's Ministry, Marcia Alford
4480 Peachtree Corners Circle
Norcross, Georgia 30092
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