BREAKAWAY CAMPFERENCE
Guest Student Registration Form
Attendee Name
First Name
Last Name
Email Address
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone #
Please enter a valid phone number.
Grade (coming out of)
Please Select
5th
6th
7th
8th
9th
10th
11th
12th
Gender
Please Select
Male
Female
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Activity Release
Required for all students attending BREAKAWAY Campference.
FOR INDIVIDUALS 18 YEARS OF AGE OR OLDER, ALL PARENTS, AND ALL LEGAL GUARDIANS I consent to allow any of my children listed below to participate in any activity or trip sponsored by Grow Church (“Church”). In consideration of the Church allowing me or any of my children listed below to attend any activity, I execute the following release. In the event of an emergency where medical treatment is necessary, I authorize the Church to obtain the services of a licensed physician and/or certified paramedic for me and/or any of my children listed below. I agree that any such expense will be my obligation. Please attempt to notify me immediately concerning any such emergency. I, (PLEASE PRINT) _____________________________________ individually, or in my capacity as a parent or legal guardian, expresses a full and complete release of any liability and indemnification, past or future, which may be claimed against the Church, and its agents, trustees, officers, employees, members, attendees, representatives, any volunteers and specifically including, but not limited to, all claims and demands of whatever nature, actions, damages, costs, loss of services, expenses and compensation on account of or in any way growing out of personal injuries, illnesses, and/or property damage having already resulted or to result at any time in the future, whether or not contemplated at the present time or whether or not they arise following the execution of this release. For the consideration stated above, I further agree that in the event that my child or I should make any claim against the Church for damages arising out of the above named activity, we will personally indemnify, defend, and hold harmless the Church, and its agents, trustees, officers, employees, members, attendees, representatives, and any volunteers against any and all loss and damaged occasioned thereby, including attorney’s fees. I understand that the Church may take photographs and/or other media (“Media”) of me and my family in the course of its activities, and I grant the Church permission to publish such Media in a manner the Church deems appropriate. This Activity Release Form is in effect for ALL events or activities that I, or any of my children, may participate in. This release form is revocable, prospectively only, by a writing signed by me that bears the date that the revocation is delivered to the Church. [PRINT PARENT/GUARDIAN NAME:]
Print Name of Student/Attendee & DOB
Mobile Phone (of Parent)
Family Physician/Emergency Contact and Phone
Special considerations or needs (allergies, asthma, etc.)
I have read and understand this release form and have willingly placed my signature below as evidence of my acceptance of all the conditions contained in this document. [Print parent name if student is a minor OR student name if not a minor]
Additional Info
What t-shirt size? (unisex adult size)
Please Select
Small
Medium
Large
X-Large
XX-Large
Does the attendee have food allergies/restrictions? If yes, please specify.
Submit
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