Please fill out the form below fully and with accurate, up-to-date information. This form MUST be filled out for a teen to be able to attend activities at Heritage Baptist Church.

I, the undersigned parent or guardian, hereby consent for my child to participate in the Heritage Baptist Church of Wallingford, CT, NAVIGATE Youth Ministry activities from August 30, 2019 through August 28, 2020 as listed below. I certify that my child is able to participate in physical activities as directed by Heritage Baptist Church youth workers. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them on the registration form. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize Pastor Robert Treloar, Mrs. Anna Treloar, or Mrs. Kerri Urbanowicz to make emergency medical decisions for my child. If there are any activities in which I do not want my child to be involved, I have listed them on the registration form. I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED DURING THE PROGRAM, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold Heritage Baptist Church and its agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by law of the state of Connecticut and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full and legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.

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