DNOW 2023 February 17th-19th

Name of Student*

First NameLast Name

Parent and/or legal guardian of Student participant*

First NameLast Name

Address

Mom Cell*

Please enter a valid phone number.

Dad Cell*

Please enter a valid phone number.

Birth Date*

Date

Academic Grade*

Name of School (If homeschooled, please put that here)*

Parent Email

example@example.com

Functions and Activities

It is my understanding that participating in the programs, mission and recreational, and other activities at Summit Heights Fellowship is a privilege. Prior to my child's participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

I {parentguardiansName} give {churchName} my permission for my child to participate in all give activities including but not limited to camps, mission trips, water sports, field sports and any other recreational activity.

Release of Liability

By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me currently. I further release Summit Heights Fellowship/ Holly Brook Baptist Church and any churches involved in DNOW and its pastors, leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall exclude any gross claims of negligence. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against Summit Heights Fellowship any churches involved in DNOW or its pastors, leaders, employees, volunteers, or agents.

I further agree to indemnify and hold harmless Summit Heights Fellowship/ Holly Brook Baptist Church and its Pastors, leaders, employees, volunteers, or agents from any and all claims arising from my child's participation in its activities and programs, or as a result of injury or illness of my child during such activities.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of Summit Heights Fellowship/ Holly Brook Baptist Church and any churches involved in DNOW to seek and secure any needed medical attention or treatment for the child named above, including hospitalization, if in the agent's opinion such need arises. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.

Special Events and Field Trips

I understand that the student named above may be participating in local/ non-local service projects and fellowship events during church events. I understand that during this period my child may take part in activities such as: construction, minor yard work, mowing, cleaning, painting, and other activities consistent with the purposes of the church.

Insurance Company

Policy #

Insurance Company Phone Number

Medical Doctor

Medical Doctor's Phone Number

Guardian 1*

Relationship*

Primary Phone Number for Guardian 1*

Work Phone Number for Guardian 1

Guardian 2

Relationship

Phone Number for Guardian 2

Work Phone Number for Guardian 2

Medical History

Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc: Other information leaders should know about the student or adult participant:

For Use only if the Participant is a Minor

I represent that I am the parent/guardian of {nameOf}. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of Summit Heights Fellowship, including any special events/activities described above. In consideration for allowing the participation of the child in the activities of Summit Heights Fellowship/ Holly Brook Baptist, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

Signature of Parent or Legal Guardian*

Name of Parent or Legal Guardian*

Participant/Parent Signature*

DNOW 2023 February 17th-19th

Student Info

Parent / Guardian Information

Concerning the cost of DNOW

"Time Away" Card

Yearly Permission / Medical Waiver

Health Insurance Information

Emergency Contacts