Clone of Hearts on Fire - 2024

1

Child's Full Name* This field is required.

First Name

Last Name

2

By checking below, you give permission for your child to attend the following activity :* This field is required.

Hearts on Fire Trip - November 21-23, 2025

3

a. I understand that my child is expected to behave responsibly and respectfully.* This field is required.

Yes

4

b. I agree and understand that I am responsible for the actions of my child, and I release CRBC from all claims and liabilities that arise in connection with the trip, except if due to the negligence of church staff.* This field is required.

Yes

5

c. I confirm that my child is medically fit and able to participate in all activities described above. Choose No, if you need to list any exceptions or activities your child cannot participate in.* This field is required.

YESNO

6

Activities my child cannot participate in:

7

d. My child has medical or dietary needs that the church needs to be aware of. (If you choose Yes, you will be able to list those next.)

YESNO

8

List any medical needs (including medications) or dietary restrictions. Include any relevant allergies as well.

9

e. I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child.* This field is required.

Yes

10

Emergency Contact Name:* This field is required.Probably you or your spouse.

First Name

Last Name

11

Phone Number* This field is required.

Area Code

Phone Number

12

Additional Contact* This field is required.

First Name

Last Name

13

Phone Number* This field is required.

Area Code

Phone Number

14

Signature of Parent/Guardian* This field is required.By signing below you agree to all rules and conditions listed above. You can use mouse, or finger on touch screen device to enter signature.

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15

Name of Parent/Guardian* This field is required.

First Name

Last Name

16

Date* This field is required.

Date