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East Lake Expression Engine Application
Waiver and Release (sign at the bottom)

Please read carefully: Parents, you are assuming the risk and legal liability and releasing all claims for injuries, damages or loss which your child might sustain as a result of participating in any and all activities, including transportation.

I acknowledge that there are certain risks of physical injury, and I voluntarily agree to assume the full risk of any and all injuries, damages, or loss, regardless of the severity that my child may sustains as a result of participation. If my child is injured, becomes ill, or needs medical attention for any reason, and I cannot be contacted, this authorizes program staff to assist my child and/or call for medical assistance.

I understand I am responsible for all costs incurred in any such medical emergency. I have read and fully understand this waiver and release, and my signature gives my consent.

Email address *
Child's Name *
First and last name
Your answer
Age *
Your answer
School *
Your answer
Grade *
Your answer
Name of Teacher *
Your answer
Birth Date *
MM
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DD
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YYYY
Boy or Girl *
Lives with: *
Who has legal custody? *
Your answer
Mother's Name *
Your answer
Age *
Your answer
Address & Zip Code *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Email *
Your answer
Phone *
Your answer
Employed at *
Your answer
Church *
Your answer
Pastor's Name *
Your answer
Father's Name *
Your answer
Age *
Your answer
Address & Zip Code *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Email *
Your answer
Phone *
Your answer
Employed at *
Your answer
Church *
Your answer
Pastor's Name *
Your answer
Name of people who may pick up my child (up to 4 names) *
Your answer
Name of people who may NOT pick up my child (up to 4 names) *
Your answer
Emergency Contact 1 (other than parent) Name *
Your answer
Emergency Contact 1 Relationship *
Your answer
Emergency Contact 1 Home Phone *
Your answer
Emergency Contact 1 Cell Phone *
Your answer
Emergency Contact 2 Name *
Your answer
Emergency Contact 2 Relationship *
Your answer
Emergency Contact 2 Home Phone *
Your answer
Emergency Contact 2 Cell Phone *
Your answer
Allergies/Illnesses *
Your answer
Medications *
Your answer
Family Doctor *
Your answer
Family Doctor Phone *
Your answer
Insurance Co *
Your answer
Insurance Co ID# *
Your answer
Hospital *
Your answer
Signature Of Agreement In Regards to Wavier & Release (Up at the top) *
Your answer
Date Of Agreement Upon Wavier & Release (Up at the top) *
MM
/
DD
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YYYY
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