Off Campus Waiver
One Child per Waiver
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Name
First Name
Last Name
Father's Phone Number
Please enter a valid phone number.
Mother's Name
First Name
Last Name
Mother's Phone Number
Please enter a valid phone number.
Other Emergencey Contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
Do you wish to have your child's doctor contacted in case of emergency?
Yes
No
If yes, Doctor's Name
First Name
Last Name
Doctor's Phone Number
Please enter a valid phone number.
Emergency Authorization
I, the undersigned, parent or legal guardian of the above named individual, hereby authorize treatment and/or care at any hospital in case of emergency. If there is an emergency and I can not be reached, contact the above emergency contact.
Signature
Clear
Waiver of Liability
I, the parent or legal guardian of the above named individual, release, discharge, and hold harmless Creekside Church, its employees, volunteers and other representative from any claims arising out of or relating to any physical injury that may result to said individual while participating in Creekside Church sponsored events, including any physical injury resulting by the negligence of any employee, parent or volunteer while performing his/her duties during any event or activity.
Signature
Clear
Insurance Information
Participant Name
Insurance Company
Policy Number
Group Number
Phone Number
Please enter a valid phone number.
Submit
Should be Empty: