412 WKND August 14-16

Students Name

First NameLast Name

Students Birthday

Date

T Shirt Size

Parents Name

First NameLast Name

Parents Email

example@example.com

Parents Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Any allergies, Medications, or general information about your student we need to know?

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.

PERSONAL RESPONSIBILITY - We understand all children are angels BUT in the event a student is continually disruptive, is unable to follow directions, is resistant to participating, or otherwise hostile despite efforts to address behavior, the parent/guardian understands they will be responsible to pick up the child from the church when notified without refund. Likewise, if a student's health deteriorates to a point in which it become untenable for the sponsors to handle, parents will be notified and required to collect the child for more adequate treatment and care.

Signature