Information received is confidential and is being gathered for the purpose of serving your child while in the care of Abundant Life Chapel Any medical information gathered here serves to authorize Abundant Life Chapel, it's staff. and volunteers to obtain medical assistance in emergencies.

**In case of custody agreements, please include the proper form authorizing parental contacts.

 In case of emergency, every effort will be made to contact parent/guardian named above. Please provide an alternate emergency contact in the event we are unable to do so.

I, the parent/legal guardian of the above student hereby authorize REFUGE Youth of Abundant Life Chapel to use the name/image of the child named above in its public relations and communication materials created for a period of two years from date consent is signed. I realize that I may withdraw my consent in writing at any time by contacting the REFUGE Youth leadership team. 

I understand that the photograph/ video(s) may be used in a publication, print advertisement, direct-mail piece, electronic media (ie: video, internet, church website, social media, etc.) or other form of communication. 

In giving my consent, I hereby release and hold harmless REFUGE Youth, Abundant Life Chapel and their agents, staff, employees, officials, representatives and contractors from any and all responsibility or liability for damage of any kind suffered in any manner whatsoever. 

I hereby relinquish any and all personal or proprietary rights I may have in connection with such use. I understand that I will receive no compensation should any photograph of me be used.