LIABILITY RELEASE, PERMISSION, CONSENT TO TRAVEL

I, ___________________________________, being an adult (18 years or older) and the parent/legal guardian of __________________ (name of minor), do hereby release First Baptist Lavaca Church, its agents, assigns, employees, and volunteer assistants from any liability whatsoever arising out of injury, sickness, damage, or death which may be sustained by the above minor during any activity, function, or the like sponsored by First Baptist Lavaca Church during the Choir Competition __________________ (date).

MAIN EMERGENCY CONTACT

Please complete the following information for the minor’s parent/legal guardian:

NAME__________________________________________________________

ADDRESS______________________________________________________

CITY_____________________________STATE_______ZIP_____________

HOME PHONE___________________CELL PHONE__________________

ALTERNATE EMERGENCY CONTACT

In case of emergency and we are unable to reach the main emergency contact, who would you like us to attempt to reach?

NAME______________________RELATIONSHIP__________PHONE_____________

By signing below, I affirm that I totally agree to all of the above statements and that all of the information provided on this form is complete, accurate and true to the best of my knowledge.

_____________________________________
Signature of parent or legal guardian

Date_________________________________

_____________________________________
Print name of parent or legal guardian

_____________________________________
Signature of other parent or legal guardian (if applicable)

Date_________________________________

_____________________________________
Print name of other parent or legal guardian

FILING INSTRUCTIONS: The Entry Form, release forms and the Official Rules are available at the First Baptist Lavaca Church Office located at 100 West Main Street, Lavaca, Arkansas 72941. Completed Entry Forms can also be faxed to the First Baptist Lavaca Office at (479) 674- 2293. (Attention: Choir Competition). No Entry Form received after May 14, 2007 will be considered. If you have questions about this form, please call: Dee Mathes 479-674-2173 voice/tty (or) Jill Burt 479-414-5283

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