Activity Waiver

2019 Student Liability Release

* Indicates required field

Student Name: First - Last *

First

Last

Age: *

Grade: *

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

In case of emergency, notify: *

Emergency Contact Number: *

Doctor: *

Doctor Number: *

Health Insurance *

Yes No

Name of Provider: *

Policy Number: *

Provider Address: *

Allergies // Medications *

"The undersigned, in consideration of participation of this program, agrees to indemnify hold harmless and release the Dearing Christian Church, its members, employees, and associated personnel, whether paid of volunteer agains all claims demands and causes of action related to injury, disability, death, or any other loss or harm to person or property resulting from my child's participation in this program arising from the negligence of the releases or otherwise, to the fullest extent permitted by law.

I have read the agreement and fully understand that I assume all risk for injuries. *

Yes

Dearing Christian can use pictures/video of my student for promotion and reflecting back on events. *

Yes No

"In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for the person named above, as deemed necessary. I also agree to accept full financial responsibility for the cost of such treatments."

Upload a screenshot of your signature below.

Signature of Parent of Guardian: *

Max file size: 20MB

Submit