Registration & Waiver

Name of Student

First NameLast Name

Birth Date

MonthDayYear

Name of Parent/Guardian

First NameLast Name

Parent/Guardian Ph. #

Area CodePhone Number

Parent/Guardian E-mail

Student's Email (Optional)

I would like to receive The Youth Network email updates (optional).

Does your child have any allergies (Bee stings, penicillin, other drugs) or dietary restrictions?

Other

Does your child consistently carry medication (Antibiotics/Epi-Pen)?

Other

Does your child have any physical, emotional, mental, or behavioral concerns or limitations that our staff should be aware of?

Other

Additional Comments

Do you grant permission for future reasonable & safe use of pictures/videos containing your child/teenager (i.e. social media, website, bulletin).

In the case of off campus events, do you, the guardian, grant permission to our Youth Staff to drive your teenager/child or if necessary use transit?

Precautions are taken for the safety and health of your child, but there is a risk of accident or illness. In such a case, Living Waters Church, its staff, and its volunteers are hereby released from any liability. In the event if your child requires special medication, x-rays or treatment, we will make every effort to notify the parents/guardians immediately.

Parent/Guardian Signature (Use cursor to sign in Box)

You will received a confirmation email once the form is submitted. If you do not receive it, the form has not be submitted.

General Waiver