EmailMe Form - COV. PRES. JR. HIGH MODGNIK REGISTRATION

Name(s) *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone *

### - ### - ####

Grade(s) *

Total students registered: *

Amount to donate for scholarships:

$ Dollars . Cents

Parent Email *

Student Email

I would like to room with:

Late arrival

I'll be arriving late & providing my own transportation.

Health Insurance Provider *

Policy #: *

Any allergies and/or medical needs? *

T-shirt size(s) (Youth Medium, Youth Large, Adult Small, Medium, Large, X-Large, XX-Large): *

Emergency Contact: *

Phone # of Emergency Contact: *

### - ### - ####

PLEASE READ, SIGN & DATE

I/We understand that there are inherent risks involved in any ministry or athletic events; 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(ren)’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 I/we will be ultimately responsible for 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(s) named above.  I/We also agree to bring my/our child(ren) home at my/our own expense should he/she become ill or if deemed necessary by the youth ministries staff member. 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(ren).  I/We, the undersigned, have legal custody of the student(s) named above, a minor(s), and have given my/our consent for him/her to attend MODGNIK 2023.

Parent/Guardian Signature *

Clear

Parent/Guardian Signature

Clear

Date *

MM / DD / YYYY