Winter Retreat Registration 2018
Full Name *
Your answer
Youth Cell Phone Number: *
Your answer
Parent/ Guardian Names: *
Your answer
Parent/ Guardian Cell Phone Number *
Your answer
Youth Date of Birth *
Your answer
Current Grade *
Your answer
Medical Insurance Company *
Your answer
Policy # *
Your answer
Physician *
Your answer
Address *
Your answer
Office Phone Number *
Your answer
Current Medications and Dosage *
Your answer
Allergies
Your answer
Physical Disabilities *
Your answer
May your child be given basic medications, if needed? (Tylenol, Tums, Advil, Immodium, ect.) *
Does this child's activaties need to be restricted for any reason? *
If yes, please explain: *
Your answer
Church attending
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. Additionally, it allows the church to use images or videos of named child in future publicity for the Church. I/We, the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents and volunteer workers from any and all liability for any injury, loss or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible fort the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home and my/our own expense should they become ill or if deemed necessary by the student ministries staff member. I/We grant to the Church its representatives and employees the right to take photographs of my child in connection with the Church Vacation Bible School. I/We authorize the Church, its assignees and transferees to copyright, use and publish the same in print and or electronically. I/We agree that the Church may use such photographs of my child with or without his/her name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. *
Parent/ Guardian Signature and Date:
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