NAME OF STUDENT*
GENDER OF STUDENT*
STUDENT'S DATE OF BIRTH*
PRIMARY ADDRESS WHERE STUDENT RESIDES*
STUDENT'S EMAIL ADDRESS
(Please only list students email here, if applicable. If contact via parent only is preferred, please leave blank.)
STUDENT'S CELL/HOME PHONE
(Please only list students number here, if applicable. If contact via parent only is preferred, please leave blank.)
(For the current school year)
KNOWN ALLERGIES OR MEDICAL CONDITIONS*
IS ACTIVITY SPONSOR AUTHORIZED TO APPROVE MEDICAL TREATMENT?*
IS THE STUDENT COVERED BY PERSONAL/FAMILY MEDICAL INSURANCE?*
HEALTH INSURANCE COMPANY
POLICY ID NUMBER
NAME OF PRIMARY INSURED
DATE OF LAST TETANUS SHOT OF STUDENT*
NAME OF PARENT/GUARDIAN*
RELATIONSHIP TO STUDENT*
I HEREBY WARRANT THAT I AM THE SOLE PARENT/GUARDIAN OF THIS STUDENT AND THERE IS NO OTHER PARENT/GUARDIAN RESPONSIBLE FOR THIS STUDENT.*
Yes, I am the sole guardian of this student.No, I share guardianship of this student.
NAME OF PARENT/GUARDIAN*
THIS PARENT RESIDES AT A DIFFERENT HOUSEHOLD THAN THE PREVIOUS PARENT*
NAME OF EMERGENCY CONTACT*
I acknowledge that participation in our event activities involve risks to the Participant (and to Participant’s parents or guardians), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage.
In consideration for the opportunity to participate in the activities, the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the Activities. Messiah’s House or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “Activity Sponsor”) will make every reasonable effort to first reach the Participant’s parent/guardian prior to any medical care, other than emergency treatment, being given to the Participant. The Participant (or parent/guardian) accepts personal financial responsibility for: any injury or other loss sustained during the Activities or during transportation to and from the Activities, expenses related to disciplinary actions, or any medical treatment rendered to the Participant that is authorized by the Activity Sponsor. Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Activity Sponsor for any injury arising directly or indirectly out of the described Activities or transportation to and from the Activities, whether such injury arises out of the negligence of the Activity Sponsor, the Participant, or otherwise.
I, the Participant (or legal parent or guardian with legal authority to sign this agreement on behalf of the child), hereby grant, voluntarily and with full understanding, to Messiah’s House (“Church”), a license to use and store the Participants name and image, by means of digital or film photography, video photography, audio recording or other documentation, with respect to the Activities, of Church for printed or electronic publications of Church and any Web site created by or for Church for its sole benefit.
If a dispute over these agreements or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the America Arbitration Association.
We, the Participant and parent/guardian representing ALL legal parents/guardians, hereby certify that we have carefully read the foregoing and acknowledge that we understand and agree to all of the above terms and conditions. We are aware that by signing this agreement we assume all risks and waive and release certain substantial rights that we may have or possess against the Activity Sponsor.
PRINTED NAME OF STUDENT*
SIGNATURE OF STUDENT*
(To sign, click and hold your mouse and draw your signature, or use a signature pad, in the blank space below.)
PRINTED NAME OF PARENT/LEGAL GUARDIAN*
SIGNATURE OF PARENT/GUARDIAN*
(To sign, click and hold your mouse and draw your signature, or use a signature pad, in the blank space below.