Basketball Insurance and Permission Form

Insurance Agreement

In order to save the expense of the purchase of a separate policy for me or my child, I hereby confirm that I or my child is covered and will remain covered under a policy of medical insurance with the company listed on the Registration Form. If my coverage changes to another company, I will promptly notify First Baptist Church.

I further agree that my insurance company will be the primary source of coverage in the case of an injury or accident involving myself or my child while participating in the Basketball League, and that I am responsible for any deductible expense in connection with that coverage.

I also understand that after the exhaustion of the primary insurance benefits of my policy, and the payment of any deductibles thereunder, I may file for secondary coverage under any policy maintained by First Baptist which provides for such expenses.

Permission Clause:

As a participant in the Activities Ministry of First Baptist Church and in the event of accident, illness, or injury, I hereby grant permission to staff or representatives of First Baptist Church on the Square to administer necessary first aid, and/or take me to the nearest medical facility for additional treatment.

Name of Participant: (Please Print)

_____________________________________________________________

Program in which you are participating: Basketball 2007

Signature of Participant or Parent:

___________________________________________________

Date: _______________

If you have any questions about the activities ministry, recreation or sports at First Baptist Church, email us at activities@fbclagrange.org or call Gerry Lord at (706) 884-5570.