Child's Name
*
First Name
Last Name
Age
*
Additional Children
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Lifepointe Fellowship-Liability Release Form
As a participant or parent/guardian of below minor child and participant in the programs or events of LIfepointe Fellowship, I do hearby release, forever discharge and hold harmless Lifepointe Fellowship, and the directors / pastors / volunteers thereof, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses. This release covers transportation and/or drivers provided by Lifepointe Fellowship and its representatives who are properly licensed to drive in the United States. This release also covers meetings on Lifepointe Fellowship property or any other site during programs and activities; also consent to emergency medical or dental treatment, including examination, diagnosis, treatment, anesthetic, and surgical treatment, the undersigned agrees to pay all costs and expenses.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Insurance Company
*
Policy Number
*
Insurance 8xx Phone Number
*
Known allergies/Medical Problems/Medication
*
If registering more than one child, please indicate which child has allergies/medical problems/medication.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Continue
Continue
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