FALL RESET

Birth Date

MonthDayYear

Grade

Student Name

First NameMiddle NameLast Name

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent's Phone Number

Format: (000) 000-0000.

Parent's Email

Additional Comments about your child we should know? Allergies,Meds,ETC

I hereby release and agree to hold Regency Park Baptist Church harmless from, and waive on behalf of myself, my children, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of RPBC, or that may otherwise arise in any way in connection with time or interaction with RPBC, members or students. I understand that this release discharges RPBC from any liability or claim that I, my child(ren), my heirs, or any personal representatives may have against the church with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any interaction with RPBC. This liability waiver and release extends to the church together with all pastors, staff members, students or church members. Parent signature is required below.

By registering for this event, the student and their parent/guardian acknowledge and agree that the student is expected to abide by all rules, regulations, and instructions established by event leaders and staff. Failure to comply with these expectations may result in immediate dismissal from the event. In such cases, the parent/guardian will be notified, and the student will be required to return home at the parent/guardian’s expense.

By signing this form you agree that your student can attend Frontier City and ride rides there and stay the night at host homes.

Signature