Student Name *

First Name

Last Name

Phone

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

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Alternate Emergency Contact *

First Name

Last Name

Phone *

(###)

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Medical Liability Release and Discipline Policy *

In consideration for being accepted by Glenn Park Christian Church for participation in all activities for the year of 2023. I, do for myself hereby release, forever discharge and agree to hold harmless Glenn Park Christian Church and the directors thereof from any and all liability, claims, or demand for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participation in any activity or trip for the year of 2023. I also give authorization for my child’s photo(s) to be used in print and electronic publications as pertains to Glenn Park Christian Church. Furthermore, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. I further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto. I am the parent or legal guardian of this participant, and hereby grant my permission for him/her to participate fully in all activities. I understand that every effort will be made to contact me prior to the administering of any medical treatment and hereby give my permission to take said participant to a doctor of hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all transportation costs. Parents/Guardians, please read and discuss the following with your student or child: On all of our events, we have certain expectations regarding behavior which will insure that we all have a great experience. If, during this event, you are unwilling to maintain these expectations, please understand that you will be sent home and/or (if under 18) parents will be notified.

I agree

I do not agree (this option would disqualify your student from participation)

Today's Date *

MM

DD

YYYY