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The WKND Release Form

*First Name

*Last Name

*Email Address

*Phone Number

*Gender:

MaleFemale

*Date of Birth:

*Grade:

*School:

*Campus You Attend:

If you are a visitor, who did you come with?:

Two friends you'd like to room with:

Father/Guardian's first and last name:

Father's Cell:

*Mother/Guardian's first and last name:

*Mother's cell:

Does your child have any limitations that would keep them from participating in the activities?

Emergency Medical Information & Authorization I give my permission for the adult counselors from Community Life Church to seek and authorize medical treatment for my child in the case of injury or illness. I agree to pay for any medical treatment that is not covered by my insurance.

Allergies or Special Needs:

All medications must be given to an adult counselor.:

Medications and times administered:

Insurance:

Policy number:

*In the event I cannot be reached, I authorize the following person to care for my child:

Relationship:

*Address and Cell Number:

*Media Release for a Minor I, the undersigned, being legal guardian of the minor listed above, grant to Community Life Church the right to use his/her photograph, likeness, video, or voice recording with or without his/her name, for social media and Community Life publications. I hereby release any claims of copyright, libel, slander, violation of privacy or similar right that I may have. There is no expiration date on this release; I will not seek compensation for usage.

I have read and agree to the Media Release for a Minor:

Yes, I agreeNo, I do not agree

*I acknowledge that by typing my name below, it acts as a binding signature.

Parent/guardian's Electronic Signature:

Expectations for Conduct c|Life carefully selects all leaders for NextGen events, and we expect all attendees to be respectful towards those leaders. Being respectful includes, but is not limited to, being where they are supposed to be and doing what is asked of them.

I have read and agree to follow the Expectations for Conduct. I acknowledge that by typing my name below, it acts as a binding electronic signature.:

*Electronic Signature:

Grant of Permission, Discipline & Release

I grant the permission, and give the authority for medical treatment as stated on the first page. I understand that should my child fail to behave in accordance with the Expectations for Community Life Church, or otherwise become disruptive, as determined by the church's Student Ministry, I will come pick up my child or they will be sent home on public transportation at my own expense. I understand that I or someone I designate will be notified by phone in such an event. If I cannot be reached by phone, I agree to reimburse Community Life Church for any expenses incurred in returning my child home, including costs of public transportation for my child and a chaperone as necessary. I understand this event has risks of injury. I will not hold Community Life Church or any of the counselors responsible if injuries occur.

I understand and agree to the disciplinary release. I acknowledge that by typing my name below, it acts as a binding electronic signature.:

*Parent/Guardian Electronic Signature:

*Date:

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