EmailMe Form - COV PRES MODGNIK LEADER REGISTRATION

Name(s) *

Address *

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

Phone *

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

Email *

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) (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 involvement.  In the event that I/we is/are injured and require 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 person(s) named above. I/We also agree to bring myself/ourselves home at my/our own expense should I/we 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 above named person(s).

Signature *

Clear

Signature

Clear

Date *

MM / DD / YYYY