Participant Name * First Name Last Name Parent/Legal Guardian Name * First Name Last Name Parent/Legal Guardian Email Address * Emergency Contact Name * Emergency Contact Relationship * Emergency Contact Phone * (###) ### #### Allergies Other Medical Conditions Physician's Name * First Name Last Name Physician's Phone Number (###) ### #### Medical/Hospital Insurance Company * Policy Holder's Name * First Name Last Name Emergency Hospital * I/We understand all reasonable safety precautions will be taken at all times by Living Stones Christian Church and its agents during and transportation to/from events and activities. I/We authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold Living Stones Christian Church, its leaders, employees, or volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. * I agree with the disclosure above. I/We authorize any treatment by an accredited first aid respondent, hospital and/or physician deemed necessary for the subject of the release in case of an emergency. * I agree with the disclosure above. I have read and fully understand the above waiver and release of all claims. By checking the box and submitting this form, I certify that I am the parent/guardian of the individual represented above, and that I agree to the terms as stated. * I agree with the disclosure above. Thank you!
