Disciple Now 2019 - March 15-16, 2019
Activity Permit & Waiver Form (Please read the WHOLE paragraph and sign below)
As parent (s) of (YOUR CHILD) I consent to him or her to participate in the church sponsored activity of Disciple Now 2018 on March 2-4, 2018. In consideration of the church sponsoring this activity, I hereby waive, release and agree to hold harmless Edgewood Baptist Church, its agents, employees and volunteer assistants from any and all claims for injuries and/or damages which may occur to or be suffered by said youth while going to or from this said event or during said event, or loss of property while going to or from this event or during this event. The undersigned further authorizes the person in charge of this activity, in his or her discretion, in case of sudden illness, injury or emergency involving the above-named youth, to obtain for said youth, any necessary hospital, medical and first-aid care. *
Type your name below consenting to this Waiver
Your answer
Student's Name *
Your answer
Contact Numbers
(Please give us phone numbers for Parents/Guardians)
Cell Number (Mom or Guardian)
Your answer
Cell Number (Dad or Guardian)
Your answer
We have the following medical insurance co. *
(Provider Name) ie: Anthem, Bluecross, etc
Your answer
Insurance Phone Number *
(Should be on medical card)
Your answer
Policy Numbers *
(Identification Number or Group Number)
Your answer
List out any Medications or Allergies
Your answer
What grade are you in?
TShirt Size *
(We only have Adult Small-XXXXL)
Is there a student that you need to be with for the weekend?
Your answer
Dnow is $30 for one student and $50 for the whole family (Check below how you will pay) *
Place payment in the envelope and then the BLACK mailbox in the youth room mounted to the first column
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