Ziplining — LIFEHOUSE CHURCH

STUDENT INFORMATION

Name *

Name

First Name

Last Name

Birth Date *

Birth Date

YYYY

Address *

Student Phone Number

School *

EMERGENCY CONTACT INFORMATION

Name of Parent/Guardian *

Name of Parent/Guardian

First Name

Last Name

Parent/Guardian Phone Number *

Parent/Guardian Email *

MEDICAL INSURANCE

Medical Insurance Carrier *

Doctor Name *

Doctor Phone Number *

Parental Release *

I hereby authorize my child to attend Ziplining 2016 and state to the best of my knowledge my child is healthy and fit for an active program. I acknowledge that there may be the inherent possibility of risk and therefore release all parties involved from any liability for loss, damage, injury, disease or death involving my child, resulting from any activities during this event taking place on Oct 22nd 2016. Further I authorize the staff and/or volunteer adult leaders for this trip to consent for any medical care, dental care or both in the event that it is needed, in the event that I cannot be reached. Lifehouse Youth Group or The Lifehouse Church are not liable for lost or stolen property.

By checking this box you are confirming that you are the parent/guardian of the student attending this event and Student Ministries to text message for confirmation

Question or Comment