Elevate Registration 2023 PRSM

Name of participant/student*

Address*

Student Gender*

MaleFemale

T-Shirt Size*

Students Current Grade*

Parents Phone Number*

Parents Email Address*

example@example.com

Name of Emergency Contact*

Emergency Contact Phone Number*

Medical conditions, allergies, etc.?

Is sponsor authorized to approve medical treatment?*

Is sponsor authorized to administer over the counter pain relievers (such as Tylenol, Advil)?*

Is participant covered by personal/family medical insurance?*

If yes, name of insurer

Policy or group number

Participation Agreement By signing below, the participant (or parent /guardian, if participant is a minor) acknowledges and accepts the risks of physical injury associated with the participation in the activity described above. Except for gross negligence on the part of the sponsor, the participant, or parent/ guardian, accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further the participant, parent/ guardian, promises to hold harmless the sponsoring organization and its representatives for any injury related to the activity. The sponsoring organization is authorized to get medical treatment forthe participant if need arises. If a dispute over this agreement of any claim for damages arises, the participant, & parent/guardian agree to resolve the matter through a mutually acceptable arbitration process.

I am also giving PRFBC permission to transport my Student/Students if transportation is needed to and from approved host homes. And I understand my Student/Students will be staying at an approved PRFBC Host Homes during this event.

Payment Options*

Check to Church OfficeVenmo

Parent Name*

Date*

Date

Parent Signature*

Clear