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FOR ABUNDANT LIFE CHRISTIAN CENTER USE ONLY

***THIS FORM MUST BE COMPLETED BY THE PARENT/GUARDIAN OF EACH PARTICIPANT. INFORMATION PROVIDED WILL NOT BE SHARED***

EACH PARTICIPANT MUST COMPLETE THIS FORM

PARENTAL RELEASE FORM

Today's Date

YYYY

My child will be able to participate in the

ALCC Event

I certify that

Please enter child's name

First Name

Last Name

NAME OF KID

First Name

Last Name

BIRTHDATE

YYYY

who is in sufficiently good physical condition to engage in physical activities, and we give complete and qualified permission for his/her to do so without a health exam certified by a doctor. He/she is in good health and free from any communicable disease(s).

If, in the judgement of an officer, agent, or representative of Abundant Life Christian Center/School, the above named student should need first aid, or other immediate care and treatment as a result of any injury or illness, I do hereby request, authorize, and consent to such care and treatment as may be give to said student by any physician, athletic trainer, nurse, hospital, or representative; and I do hereby agree to indemnify and hold harmless Abundant Life Christian Center/School and it's officers, agents, or representatives from any claim or lawsuit toward any person whomsoever, relating to such care and treatment of said child. I further agree to reimburse Abundant Life Christian Center/School for any medical expenses incurred on behalf of my child in connection with this activity.

Abundant Life Christian Center/School, it's officers, agents, and representatives are hereby absolved and released from any liability, legal or otherwise, for any damages to person or property resulting from an accident, injury or death occurring during or in route to or from any activities, in consideration fro being allowed to participate in said activities. I/we hereby agree not to sue or asset any claim for damages whatever against Abundant Life Christian Center/School or it's representatives and further agree that should it be the judgement of the officers, agents or designated chaperones that the interests of the individual or group you lobe best served by requiring the undersigned participate to be immediately removed or pickup up from the involved premises at the expense of an by the above sign parent(s) or guardian(s) as requested by Abundant Life Christian Center/School, it's representatives, officers, agents or designated chaperones, to be available to respond within a reasonable time to take custody and control of the child, or otherwise permit Abundant Life Christian Center/School, it's representatives, officers, agents or designated chaperones to surrender the child to an appropriate emergency service agency.

NAME OF PARENT/GUARDIAN(S)

First Name

Last Name

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SIGNATURE of PARENT/GUARDIAN(S)

Typing your full name into this field acts as a digital signature

PARENT/GUARDIAN HOME PHONE

(###)

###

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PARENT/GUARIDAN WORK PHONE

(###)

###

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PARENT/GUARIDAN CELL PHONE

(###)

###

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EMERGENY CONTACT: If we are unable to reach you in the case of an emergency, please list an alternative person you want us to contact:

EMERGENCY CONTACT NAME

First Name

Last Name

EMERGENCY CONTACT PHONE

(###)

###

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RELATIONSHIP

MEDICAL INFORMATION

NAME OF PARTICIPANT

First Name

Last Name

NAME OF PRIMARY INSURED

if none type N/A

First Name

Last Name

NAME OF HEALTH INSURANCE PROVIDER

if none type N/A

POLICY NUMBER

if none type N/A

GROUP NUMBER

if none type N/A

PRIMARY CARE PHYSICIAN

if none type N/A

PCP PHONE

if none type Parent Phone

(###)

###

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ALLERGIES

if none type N/A

CURRENT MEDICATION(S) & DOSE

if none type N/A

PLEASE LIST ANY DETAILS ABOUT YOUR CHILD (I.E. DIET, REACTIONS, EMOTIONS, ETC.) WHICH MAY BE OF CONCERN TO YOU AND WOULD AID IN CARE OF HIM/HER

if none type N/A