One form per registrant. Registration is due no later than October 4, 2018. Thank you.
Please answer the following questions about the student named above to the best of your ability.
EMERGENCY TREATMENT PERMISSION
I do hereby state that I have legal custody of this girl who resides with me while this minor is registered at the 2018 Kids Truth Conference. I authorize any director, counselor, nurse, lifeguard, or other responsible person of said event to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, to be rendered to this minor, under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state, when such medical or surgical treatment is necessary.
By attending this event, you hereby grant a license and permission to Illinois Girls Ministries or their designees, and their employees, successors, assignees, licensees, and agents to utilize your appearance, image, voice, and likeness, in perpetuity, in any and all manner and forms and format of media throughout the world, now known or hereafter devised, including but not limited to recordings, television broadcast, or webcasts of the event you are attending. You release Illinois Girls Ministries and their designees, and each of their employees, successors, assignees, licensees and agents from and against any and all claims for invasion of rights, publicity, privacy, defamation or other claims or causes of action arising out of the production, reproduction, distribution, television broadcast, webcast, exhibition or other exploitation of the event you are attending.
I hereby voluntarily waive any claim against Illinois Student Ministries, its agents, employees, successors and assignees, its National organization and all leaders of the program for any and all causes which may arise in connection with the activities of the Winter Splash or other programs. I further hereby certify that I have read the forgoing Emergency Treatment & Media Permission and know and understand its meaning and contents and have executed it as my free and voluntary act and deed for all the uses a purposes therein set forth herein.
Please ensure that your email address is correct on this form. Once you have submitted this form with payment, you will receive a confirmation at the email address you provided. Be sure to check your spam folder if you do not find it in your inbox. Your email confirmation will serve as proof of payment for the event.