Light Up Music City

Light Up Music City

June 12-16, 2023, 9a-4p
Child's Name*

First NameLast Name
Child's Date of Birth*
Rising Grade Level*
Parent's name

First NameLast Name
Parent's Email address*
Parent's Cell Number for emergency contact*
Secondary parent or guardian contact and cell number*
Medical Insurance Company & Medical ID or Group Number*
Primary Care Doctor & Phone Number*
Allergies, Medications*
Can you help drive and chaperone the week of Light Up Music City? Parents are how we make this happen!*

Yes, I am flexible on days.Yes, but I can only do certain days.No, not this year.
If you can help, what days are you available? In what capacity can you chaperone? This would include transporting students and staying with them throughout the day.
T-Shirt Size*

Youth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXLAdult XXXL
I give permission for my student to fully participate in Woodmont Christian Church youth activities and will not hold the church liable for any form of bodily harm or injury. I understand that all reasonable safety precautions will be taken by program leaders during each activity, and that the possibility of unforeseen hazard does exist. I understand the risks of my student participating in active events and agree to their participation in activities run by the church and by third parties hired by the church. By entering my name below I willfully enter into an agreement to not hold Woodmont Christian Church liable and agree to my student's full participation in activities that carry inherent risk.*
By initialing below, I consent to any x-ray, anesthetic, medical, surgical or dental diagnosis or treatment that may be deemed necessary for my minor child. Further, I understand that all efforts will be made to contact me prior to treatment. In the event that I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment including providing information included above. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. I further understand that the doctors, dentists, and other providers attending to my child will take all reasonable safety precautions during their care. Further, as a parent or legal guardian, I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the dental, medical or hospital care or treatment that is given to my child. Any policy of the church or organization sponsoring this event will be used as the secondary coverage.*
By initialing below, I give my consent for my student to be transported by Woodmont Christian Church and will assume liability for my/their permission in this activity/event and any injury that may result during their transport or at the event/activity. Further by initialing below: 1) I will not hold Woodmont Christian Church, it's officers, agents, employees, assigns or anyone acting on its behalf, responsible or liable for injury occurring to the named person in the course of such activities or travel, 2) I hereby accept financial responsibility for personal items lost by the person identified herein, 3) I authorize Woodmont Christian Church to transport and to obtain, through a physician of its own choice, any emergency medical care that may become reasonably necessary for the person in the course of such activities/events or such travel, and agree to accept the cost of the transportation and/or treatment by the medical personnel or facility, 4) I accept full responsibility and hereby grant permission for me or my minor child to travel with Woodmont Christian Church.*
I give permission for my student to be photographed during events at Woodmont Christian Church and that these photographs may be used in church publications, church bulletin boards and similar places. Please initial. If not, please simply state "no".*
Please Venmo @woodmontchristian to pay the $100/per student payment for "Light Up Music City". If you pay via Venmo, please make sure to write your student's name and Light Up Music City in the memo line. This payment covers the cost for food and fun that week. You can also bring cash or check to the church office at your convenience. We will need full payment before June 11.
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