Parent Information and Release Form
Quarry Community Church
Name of Participant: ______Event:Trout Lake 2017Date of Activity: 3/3/17 – 3/5/17
Date of Birth: ______Age: ______Grade: ______Male or Female (circle)
Address: ______E-Mail: ______
City:______State: ______Zip: ______
Emergency Contact: ______Number: ______
Home phone number: ( ) ______Social Security Number: _N/A______
Health Insurance Company:______Employee #______
Group #______Primary Physician’s Name/#:______
Parent and Student Release Statement:
As parent/legal guardian of ______, I have reviewed the information about the youth ministry activity/event and give my permission for the subject of this release to be involved in the overall activities. I give my permission to the directors, staff, volunteer leaders of Quarry Community Church to determine additional activities that would be necessary for the execution of this activity to its fullest.
I/we have reviewed the rules of the activity and agree that the subject of this release will abide by them. I/we also acknowledge that if the subject of the release has to return home early for discipline violations, it will be at my/our expense.
I/we consent to the use of any video images, photographs, audio recording, or any other visual or audio reproduction that may be taken of the subject of this release during the activity/event to be used, distributed or shown as Quarry Community Church sees fit.
I/we understand all reasonable safety precautions will be taken at all times by Quarry Community Church and its agents during the events and activities. I/we understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/we agree not to hold Quarry Community Church, its leaders, employees, and volunteers liable for damages, losses, diseases or injuries incurred by the subject of this form.
I attest that the information provided above is true and complete.
Parent/Guardian Signature: ______Date: ______
Student Signature: ______Date: ______