CYIA Pre-Training Release Form

CYIA Pre-Training Release Form
Student's Name*

First NameLast Name
Student's Birthdate*

MonthDayYear
Date
Primary Phone*
Please enter a valid phone number.
Email*
example@example.com
Do you have any allergies?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Phone*
Please enter a valid phone number.
Name of Medical Insurance Company and Policy #*
Today's Date*

MonthDayYear
Date
"I hearby give permission for the above named minor to attend and participate in the Christian Youth In Action pre-training and overnighter at First Baptist Church of Corvallis. I release and hold harmless Child Evangelism Fellowship Inc., its staff and volunteers, First Baptist Church of Corvallis, and the facilities used from responsibility and liability for any illness or injury that my child may sustain during this activity, provided they have exercised reasonable caution and supervision toward the safety of my child. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any X-ray examination, medical, dental, or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office, or in any hospital. I expect that this adult leader will notify me personally, as soon as possible if there is an accident requiring the services of a physician."*
Liability Release
Should be Empty: