Name *
Name
Address
Address
Contact Info for Emergency Contact *
Contact Info for Emergency Contact
Contact number for Secondary contact *
Contact number for Secondary contact
Does applicant have any known allergies or is applicant unable to take any medication? *
Does applicant presently take any medications regularly?
Date of last tetnaus immunization:
Date of last tetnaus immunization:
Please list Insurance Company, Name on Insurance Policy, insurance company phone number AND Policy
Mailing Address for Medical Claims (see back of insurance card
Mailing Address for Medical Claims (see back of insurance card
Does your insurance compoany require notification prior to emergency health care at a hospital? *
If yes please list phone number to call
If yes please list phone number to call
Please Read and then sign below
I hereby apply for an opportunity to attend BCM activities. I understand that the BCM is affiliated with the Baptist General Convention of the State of Oklahoma (hereafter “BGCO”). This Application and Release is voluntarily and freely made with the knowledge of the risks inherent in participating in the activities, including, but not limited to: (1) the possibility of bodily injury or property damage; and (2) the possibility of being injured in an accident while traveling in any form of transportation to the activities, during the activities, or returning from the activities. I hereby agree to participate with the BCM during activities. I hereby authorize the BCM to obtain, through a health care provider of the BCM’S own choice, any first aid or emergency medical care that may become reasonably necessary for me in the course of such activities or such travel. If such emergency care is provided, I understand that my health insurance information will be given to the health care professional and that any expenses not covered by my insurance shall be my responsibility. I understand that neither the BCM nor the BGCO will be obligated to pay any health care professional or me for any medical expenses incurred. I FULLY ACCEPT AND ASSUME ALL RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, OR DAMAGES, INCLUDING DAMAGES FOR PHYSICAL INJURY, INCURRED AS A RESULT OF MY ACCOMPANYING THE BCM TO AND FROM ACTIVITIES AND OF MY PARTICIPATION IN ACTIVITIES. I RELEASE AND HOLD HARMLESS THE BCM, THE BGCO, THEIR PREDECESSORS IN INTEREST, SUCCESSORS IN INTEREST, PRESENT AND FORMER AFFILIATES, AND ALL OF ITS PRESENT OR FORMER DIRECTORS, OFFICERS, AGENTS, EMPLOYEES, REPRESENTATIVES, SUCCESSORS OR ASSIGNS, AND ANY OWNERS OR LESSORS OF PREMISES ON WHICH THE ACTIVITIES TAKES PLACE, FROM ANY AND ALL LIABILITY, INCLUDING LIABILITY FOR PHYSICAL INJURY, ANY LOSSES, CLAIMS, DEMANDS, COSTS, OR DAMAGES THAT I MAY INCUR AS A RESULT OF MY PARTICIPATION, INCLUDING BUT NOT LIMITED TO THE NEGLIGENT, GROSSLY NEGLIGENT, OR INTENTIONAL CONDUCT OF ANY OTHER PARTICIPANT IN THE ACTIVITIES. I understand that my image may be included in a video or in photographs that may be made during activities. I understand that a promotional or highlight video may be available during or after activities. I give consent for my image appearing on videos, promotional resources, or on web sites endorsed by the BCM or BGCO.
I have hereby read the statement above the line and acknowledge all responsibility for said knowledge. *
Digital Signature *
Digital Signature
Date Signed *
Date Signed

University of Central Oklahoma Baptist Collegiate Ministry