I permit Conyers First UMC to use all of the names mentioned above and photographic
likeness in all forms and media for advertising and any other lawful purposes.
In the event of a medical emergency, I herewith authorize treatment. The authority is granted only after a reasonable effort to reach me by phone at the number listed on the other side of this form. The undersigned assumes the responsibility for any cost and releases Conyers First United Methodist Church from any liability. This release is signed on my own free will with the sole purpose of providing medical treatment under emergency circumstances in my absence.
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