Thunder Road Parental Authorization and Consent- Liability Release Statement

Thunder Road Parental Authorization and Consent- Liability Release Statement
Student Name:*

First NameLast Name
Activity Information

I understand that by signing this form I am giving permission for the listed student to participate in all activities. Every activity is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unseen events occur. By signing this form, the parent or guardian agrees to assume all risks and hazards inherent in activities. They also agree to not hold Harvest Outreach Church Assemblies of God, its' employees or volunteer assistants, liable for damage, losses and injuries to the person or property undersigned.
Name of Event: Thunder Road

Locaton: 2902 Thunder Rd S, Fargo, ND 58104

Dates and times: June 26th, 2025 Van leaves @ 10AM Returns by 4:30pm

Transportation: Van owned by Harvest Outreach Church

Cost: $30 for wristband at Thunder Road, plus one meal and snacks

Other:
Pictures and Video

We authorize Harvest Outreach Church to use our child or youth's likeness in photographs or video in any and all of its publications and other media. We will make no monetary claim or other claim against the church for the use of such photos or videos.
Discipinary Action

I understand that if my child or youth foes not conduct his/herself in a Christ-like manner while attending events of Harvest Outreach Church, my child will receive disciplinary action. If that action includes being dismissed from the event, I will be responsible for transporting my child or youth home.
Parent or Guardian:

First NameLast Name
Parent or Guardian's Signature:*

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Date:*

MonthDayYear
Date
Student Agreement
I, (students name)name* agree to conduct myself in a Christ-like manner while attending the events of Harvest Outreach Church. I will attend all required meetings and cheerfully submit to those in authority over me. I will also obey any rule which may be implemented for a specific event. I realize that failure to adhere to these guidelines will mean disciplinary action and possible dismissal from the event and return home at my parent's expense.
Student Signature:*

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Date:*

MonthDayYear
Date
Medical Information
Medical Information is on file and is currentMedical Information needs to be updated (if this is the case please fill out the HOC medical release form)
IN CASE OF EMERGENCY, and when I am unable to be contacted, I hereby give permission to the local physician to hospitalize, secure proper treatment for, order injection, anesthesia, or surgery for my child.

Students Name
Students Name

First NameLast Name
Students Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*
Gender*
Age*
Birth Date*

MonthDayYear
Date
Emergency Contact Information
Parent/ Guardian Name*

First NameLast Name
Parent/ Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Backup Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Insurance Company*
Insurance Company Email
example@example.com
Policy Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name of Policy Holder*

First NameLast Name
Birth Date of Policy Holder*

MonthDayYear
Date
Health History
Lung Trouble/ AsthmaCardiac or Kidney ProblemsDiabeticSeizuresAllergiesPenicillin or drug reactionNone of the above
If applicable, please note treatment instruction.
Restricted Activities
Current Medications
Date of Tetanus Booster

MonthDayYear
Date
Carrier of Infectious or Contagious Disease? If yes please explain:
YesNo
Any other health information we should know?

Thank You!

If you have any questions feel free to reach out to Pastor Toby!
All Information shared will be kept confidential and protected. Information will only be used in an emergency.
Should be Empty:

Thunder Road Parental Authorization and Consent- Liability Release Statement

Activity Information

Pictures and Video

Discipinary Action

Student Agreement

Medical Information

Students Name

Emergency Contact Information

Insurance Information

Health History

Thank You!

All Information shared will be kept confidential and protected. Information will only be used in an emergency.