TEENAGER INFO
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
School Grade
*
Age
*
Gender
*
Female
Male
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary & Emergency Contact Information
Primary Contact Name
*
First Name
Last Name
Relationship to Child
*
Mother
Father
Uncle
Aunt
Grand Parent
Family Friend
Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Is the address same with the child?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
*
Does the child have any medical conditions?
*
Yes
No
Please give details
Does the child have any allergies to food or medications?
*
Yes
No
Please give details
Agreement & Consent
I, parent/guardian of the participant, agree with the following statements:
*
I give permission that my child may be photographed, videotaped, and/or interviewed for the purpose of the The River's promotional use.
I understand that The River will not assume responsibility for any injury incurred while participating in athletic events, childcare programs, parent/child event and outings, special events, sports programs, or any related to Ignite Conference and The River Church sponsored activity. Certain risks of injury are inherent during participation in these programs and events. Nor will the the camp be responsible for any lost or stolen items while members and/or program participants are using the church facilities, on the church premises, or on off-site church locations. I, the undersigned for myself and my heirs, do hereby release The River and its employees and agents from any and all claims for injury, loss, or damage I may suffer as a result of my/my childs participation. This includes any injury caused by negligence, if any, of The River, its officers, employees, agents, volunteers, or the negligence of anyone else.
Date
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: