Participant Name *

First Name

Last Name

Parent/Legal Guardian Name *

First Name

Last Name

Emergency Contact Phone *

(###)

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Physician's Name *

First Name

Last Name

Physician's Phone Number

(###)

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Policy Holder's Name *

First Name

Last Name

I/We understand all reasonable safety precautions will be taken at all times by Living Stones Christian Church and its agents during and transportation to/from events and activities. I/We authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency. I/We underestand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold Living Stones Christian Church, its leaders, employees, or volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. *

I agree with the disclosure above.

I/We authorize any treatment by an accredited first aid respondent, hospital and/or physician deemed necessary for the subject of the release in case of an emergency. *

I agree with the disclosure above

I have read and fully understand the above waiver and release of all claims. By checking the box and submitting this form, I certify that I am the parent/guardian of the individual represented above, and that I agree to the terms as stated. *

I agree with the disclosure above