Youth Lock-In RSVP Form
Please complete the form to confirm your child's participation and provide emergency contact details.
Section I. Parent(s)/Guardian(s) Information
Full Name
*
First Name
Last Name
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Section II. Other Emergency Contact Information
Emergency Contact Full Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Section III. RSVP Permission
Do your child/children have permission to participate?
*
Yes, my child/children have permission to participate.
No, my child/children do not have permission to participate.
Section IV. Child's Information
Enter the name(s) and age(s) of each child who has your permission to participate.
Additional Children
*
Configurable list
Section V. Emergency Information
Allergies or Medical Information
Section VI. Activity Waiver and Permission for Emergency Treatment
I/We the undersigned, (each of us) for ourselves, our heirs, executors, administrators, successors, and assigns, covenant and agree that I/we will never sue, or bring, or in any way aid, any legal action or proceeding against Mt. Zion United Church of God, Incorporated, its legal representatives, or any and all other persons for whose acts or whom it might be liable, for any and all claims, demands, damages, costs, expenses and compensations, incurred by reason of the undersigned’s participation in the activity, event, or other listed below.Further, I/we the undersigned, (each of us) for ourselves, our heirs, executors, administrators, successors, and assigns (jointly and severally) do hereby acknowledge complete responsibility for all doctor, hospital, dental, first aid, and other medical expenses for transportation, room and board, and personal expenses which may incur while participating in the activity, event or other listed below. A person participating in anyyouth activity outside of the church campus/property/grounds may encounter ahealth emergency requiring hospitalization and/or immediate medical care andtreatment. To prevent delay in treatment,participants in such activities are strongly encouraged to sign this PermissionStatement and always retain a copy for his/her records while involved in theactivity. A copy of this PermissionStatement will be retained by the Youth Ministry Leader(s) or otherCoordinator(s). Another copy will begiven to the Church Administrator.I acknowledge and understand that in the event medical intervention is needed, an attempt(s) will be made to immediately contact the person(s) listed on this form. Reasonable safety precautions will always be taken by Mt. Zion United Church of God and its agents during the events and activities. I acknowledge and understand the possibility of risk.In the event of an emergency, illness and/or injury affecting the Participant, I, the undersigned, herebyauthorize immediate treatment and/or hospitalization recommended by and carried out under the supervision of a qualified physician or other medical personnel; including but not limited to, administering an anesthetic and performing necessary surgery.
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