4:12 Waiver & Parental Consent Form
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4:12 Student Ministries Inc. 2023-2024 School Year
Thursdays @ Lawings Chapel Baptist Church - 3:30 - 5:30

Transportation provided from Tuttle Elementary, Maiden Elementary & Maiden Middle School.
Parent Pick-Up @ Lawings Chapel Baptist Church @ 5:30

**PARENTS: Please check your email each week for our Roll Call Form. Completing this form helps us plan and organize transportation as well as keep track of all students in attendance.**
STUDENT INFORMATION SHEET
The information below is required in order for your child to attend 4:12 meetings.
Student's Name *
Student's Date of Birth *
Student's School *
Student's Grade *
Student's Homeroom Teacher *
Student's Mailing Address *
Parent/Guardian #1 Name *
Parent/Guardian #1 Phone Number *
Parent/Guardian #1 Email
Parent Interested in Volunteering
Clear selection
Parent/Guardian #2 Name
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Email
Parent/Guardian #2 Interested in Volunteering?
Clear selection
EMERGENCY INFORMATION
In the event of an emergency when parents/guardians cannot be reached, please contact the following:
Emergency Contact #1 Name *
Emergency Contact #1 Relationship *
Emergency Contact #1 Phone Number
Emergency Contact #2 Name
Emergency Contact #2 Relationship
Emergency Contact #2 Phone Number
HEALTH CONCERNS:  Please identify any allergies (including food), health problems, medications or other health concerns.
TRANSPORTATION CONCERNS: Please identify any transportation concerns, including restrictions regarding your child's transportation to/from 4:12, custody issues and any other limitations.
ADDITIONAL CONCERNS: Provide below any additional information that is needed when working with your child
4:12 WAIVER & PARENTAL CONSENT
Please thoroughly review the following waiver and consent items

LIABILITY WAIVER In consideration of 4:12 Student Ministries Inc.,  and Lawings Chapel Baptist Church allowing the Participant to participate in 4:12 Student Ministry Inc., activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless 4:12 Student Ministries Inc., and Lawings Chapel Baptist Church, its directors, employees, volunteers and agents (collectively herein “4:12/LCBC”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the group activities. We (I), the parent(s) or legal guardian(s) of this Participant, hereby grant our (my) permission for the Participant to participate fully in 4:12 Student Ministries Inc.,  activities, including trips away from the church premises. Furthermore, we (I) [and on behalf of our (my) minor Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. Authorization and permission is hereby given to 4:12/LCBC to furnish any necessary transportation (within the limitations of church insurance and the law), for the Participant. The undersigned agree(s) to hold harmless and indemnify 4:12/LCBC for any liability sustained by the 4:12/LCBC as a result of negligent, willful or intentional acts of Participant, including expenses incurred attendant thereto.

TRANSPORTATION CONSENT The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by 4:12/LCBC. My child and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation.

PHOTO/VIDEO CONSENT I hereby grant permission to 4:12 Student Ministries Inc., and its representatives to take and use: photographs and/or digital images of me and/or my child for use at 4:12 activities, in news releases, 4:12 Facebook page, 4:12 Instagram page, and other promotional materials to include: printed/digital publications, websites, and other electronic communications.

COMMUNITY STAKEHOLDERS 4:12 Student Ministries would not be possible without the many community stakeholders that have invested in our program. While many participants are members and employees of Catawba County Schools, 4:12 Student Ministries Inc., is not associated in any way with Catawba County Schools.

STUDENT CONDUCT I, the participant, understand that I am to act in a safe and responsible fashion, to follow the instructions or directions of the persons in charge and to obey requests to comply with safety regulations. Consequences will focus on restoring peace with reconciliation among the parties involved. The goal of resolving each problem will be growth and learning through repentance and forgiveness. Any problems encountered will be handled within the group and by the adult leaders to the extent that this is possible. However, should a situation persist or become uncontrollable, the parent/guardian will be contacted and informed of the problem. Should the situation be urgent, the parent/guardian will be contacted immediately and will be responsible for picking up the minor Participant from an event or providing for his/her transportation home.

ACKNOWLEDGEMENT AND SIGNATURE I have read and understand the terms of this agreement and I acknowledge that by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that my child or I may have.


This Consent, Authorization and Acknowledgment shall be effective from and including August 28, 2023  to and including August 28, 2024.


Signature of Parent/Guardian *
Date of Parent/Guardian Signature *
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