Child's Name *

First Name

Last Name

Child's Birthday *

MM

DD

YYYY

Child 2 Name

First Name

Last Name

Child 2 Birthday

MM

DD

YYYY

Child 3 Name

First Name

Last Name

Child 3 Birthday

MM

DD

YYYY

Child 4 Name

First Name

Last Name

Child 4 Birthday

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Name of Person Responsible for Drop-Off/Pick-Up - If Different than Parent/Guardian

Name of Spouse/Au Pair

First Name

Last Name

Phone *

(###)

###

####

Secondary Emergency Phone *

(###)

###

####

Photo + Video Release *

I, the legal parent/guardian, hereby authorize and consent to the use of images or videos of my child/children listed above, with or without their name(s), by the First Presbyterian Church of East Hampton for 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 the First Presbyterian Church of East Hampton, its 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/children listed above.

I agree.

Medical Release *

IT IS MY INTENTION BY THIS AGREEMENT TO EXEMPT AND RELIEVE THE FIRST PRESBYTERIAN CHURCH OF EAST HAMPTON AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF MY CHILD CAUSED BY ANY ACT OF NEGLIGENCE OF THE FIRST PRESBYTERIAN CHURCH OF EAST HAMPTON AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES. For and in consideration of permitting my child to observe, or use any facility or equipment of The First Presbyterian Church of East Hampton, or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at the First Presbyterian Church of East Hampton in the city of East Hampton, County of Suffolk, and State of New York, beginning on the day of July 21, 2024 , the undersigned parent and/or guardian of this child: hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to my child as a result of my child's observing or using facilities or equipment of The First Presbyterian Church of East Hampton, or engaging in or receiving instructions in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. The undersigned parent or guardian for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted The First Presbyterian Church of East Hampton or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless The First Presbyterian Church of East Hampton and its officers, agents, servants, or employees from any and all claims or causes of action by my child or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of my child present any claim against The First Presbyterian Church of East Hampton and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by The First Presbyterian Church of East Hampton and said persons. The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I agree.

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Background Check Authorization *

I hereby authorize the First Presbyterian Church of East Hampton to obtain and/or request information about my criminal history and fingerprints from any entity chosen specifically for conducting this search, to release information regarding any record of charges or convictions contained in its files, or in any criminal file maintained on me, whether said file is a local, state, or national file, and including but not limited to accusations and convictions for crimes committed against minors, to the fullest extent permitted by city, county, state, and federal law. I do release said entities from all liability that may result from any such disclosure made in response to this request. I may revoke this request at any time, but that revocation must be in writing and give 30 days' notice of same.

I agree.

Date of Birth *

MM

DD

YYYY

Driver's License Expiration Date *

MM

DD

YYYY

Medical Release *

I, the undersigned, wish to voluntarily participate in the The First Presbyterian Church of East Hampton’s 2024 Vacation Bible School. In consideration for being permitted to participate in the The First Presbyterian Church of East Hampton’s 2024 Vacation Bible School, in the city of east Hampton, the state New York, and country of the United States of America beginning the twenty-first day of July, 2024, I, the undersigned, fully recognizing the dangers and hazards inherent in the The First Presbyterian Church of East Hampton’s 2024 Vacation Bible School, and any related transportation, including personal injury, property damage, or wrongful death, as well as the unknown dangers and hazards which may arise in the course of my participation in the The First Presbyterian Church of East Hampton’s 2024 Vacation Bible School, do hereby voluntarily: Agree, for myself, my heirs and my personal representative, to defend, hold harmless, indemnify, release and forever discharge, to the broadest extent allowed by law, The First Presbyterian Church of East Hampton, its trustees, officers, employees, agents, insurers, successors, assigns, from and against any and all claims, demands, actions, or causes of action on account of any damage to real or personal property or any personal injury or death that may result from my participation in the above The First Presbyterian Church of East Hampton’s 2024 Vacation Bible School. I have read this release, I understand it fully, I understand that it is legally binding, and I understand that, among other things, I am agreeing to indemnify The First Presbyterian Church of East Hampton for injuries, damages or losses I may cause and giving up rights to sue.

I agree.

Have you ever been arrested for a criminal offense? *

Yes

No

Have you ever been accused, arrested, or convicted of any sexually related crimes? *

Yes

No

Have you ever been accused, arrested, or convicted of any abuse related crimes? *

Yes

No