2024 Keystone State Outreach 
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Student's Name *
Student's gender
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Student Cell Number (if applicable) 
Student's T-shirt size
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Parent/Guardian's Name 
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Parent/Guardian email
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Emergency Contact phone number
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Allergies
Any concerns or things you'd like our leaders to be aware of about your child? 
Release and Liability
By checking the box below, I understand my spot will not be held until FBC receives my payment of $200. Checks can be made out to First Baptist Church Waynesburg and given to Mandi Restanio on or before May 1st. 
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In exchange for participation of off-site activities organized by First Baptist Church Waynesburg and/or property, facilities, and services of First Baptist Church, I agree for myself and (if applicable) for the members of my family, to the following: 1. AGREEMENT TO FOLLOW DIRECTIONS. I agree to obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by employees or representatives of First Baptist Church. 2. ASSUMPTIONS OF THE RISK AND RELEASE. I recognize that there are certain inherent risks associated with off-site trips and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge First Baptist Church, whether caused by the fault of myself, my family, First Baptist Church, or other third parties. 3. INDEMNIFICATION. I agree to indemnify and defend First Baptist Church against all claims, cause of action, damages, judgements, costs, or expenses, including attorney fees and other litigation costs which may in any way arise from my or my family’s use of or presence upon the facilities. 4. FEES. I agree to pay for all damages to the facilities caused by any negligent, reckless, or willful actions by me or my family. 5. CONSENT. I consent to the participation of myself or my family members, and agree (or agree on behalf of the minor) to all of the terms and conditions of this agreement. By signing this release of liability, I represent that I have legal authority over and custody of the minor. 6. MEDICAL AUTHORIZATION. In the event of an injury to the minor during the offsite activities, I give my permission to First Baptist Church to arrange for all necessary medical treatment for which I shall be financially responsible. First Baptist Church shall have the following powers: The power to seek appropriate medical treatment or attention on behalf of my child as may be required by the circumstances, including without limitation, that a licensed medical physician and/or hospital; The power to authorize medical treatment or medical procedures in a n emergency situation; The power to make appropriate decisions regarding clothing, bodily nourishment, and shelter. 7. APPLICABLE LAW. Any legal or equitable claim that may arise from participation shall be resolved under Pennsylvania law. 8. NO DURESS. I agree and acknowledge that I am under no pressure or duress to sign this agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this agreement if I so desire. 9. ENFORCEABILITY. The invalidity or unenforceability of any provision of this agreement, whether standing alone or as applied to a particular occurrence or circumstance, shall not affect the validity or enforceability of any other provision of this agreement or of any other applications of such provision, as the case may be, and such invalid or unenforceable provision shall be deemed not to be a part of this agreement. 10. DISPUTE RESOLUTION. The parties will attempt to resolve any dispute arising out of or relating to this agreement through friendly negotiation amongst the parties. If the matter is not resolved by negotiation, the parties will will resolve the dispute using the the following Alternative Dispute Resolution (ADR) procedure: Any controversies or disputes arising out of or relating to this agreement will be submitted to mediation in accordance with any statutory rules of mediation. If mediation does not successfully resolve the dispute then the parties may proceed to seek an alternative form of resolution in accordance with any other rights and remedies afforded to them by law. 11. PHOTOGRAPHY. I give First Baptist Church permission to use pictures taken at this event on their social media, website, and other promotional outlets. I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY ELECTRONICALLY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS. 
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