Midnight Run 2016 Permission Form

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This overnight event is for High School and Young Adult youth group members only.

Complete this form to participate in our Midnight Run service outing on Saturday, April 23rd. Students MUST arrive at Fairfield Grace at 5:00 PM. We will be leaving at approximately 8:30 PM. We will be returning at approximately 2:00 AM. Students MUST be picked up from Fairfield Grace at that time.

If you are under 18, you MUST have a parent or guardian complete this form on your behalf.

Student Name *

Primary Contact Email Address (adult contact if student is under 18) *

By signing this release, you are granting the staff/volunteers of Fairfield Grace United Methodist Church permission to take the above named student on a scheduled outing during the following date(s): Saturday, April 23rd. You are also acknowledging with your signature below that you have received notice of the scheduled service outing and agree that it is appropriate for the student to participate. By signing this Release form, you waive all liability against Fairfield Grace United Methodist Church, any staff of said facilities or any parent or volunteer should there be an accident involving the student while participating in a service outing activity during the above-listed date(s). I do hereby give permission for the student to receive medical attention in the event of a medical emergency. *

I give permission to have the student's photograph taken at any Fairfield Grace UMC event and to use the photo for any of the following but not limited to the following: appearance in a video/digital picture to be used in a multimedia presentation or an Internet web page and/or appearance in a picture to be used in a publication. Please initial below: *

I realize that Fairfield Grace UMC is not responsible for the student's personal belongings or lost or stolen items. Please initial below: *

I understand that the student must be dropped off at Fairfield Grace by 5:00 PM on Saturday, April 23rd. Please initial below: *

I understand that the student must be picked up at Fairfield Grace at approximately 2:00 AM on Sunday, April 24th. Please initial below: *

Please include any health, allergy, or other concerns you have for the student below: *

Emergency contact name (during time of event) *

Emergency contact phone number (during time of event) *

I agree with all of the statements above and give Fairfield Grace United Methodist Church permission to take the student on a service outing to: Midnight Run into New York City (leaving Fairfield Grace at approximately 8:30 PM and arriving back in Fairfield at approximately 2:00 AM). Please electronically sign your name below. *

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