Movement Youth Retreat Registration

Student Information

Name

Address

Date of Birth

Grade Next School Year

Shirt Size

Emergency Contact

In case of emergency, contact (Parent/Legal Guardian)

1. Name

Phone

Relationship

2. Name

Phone

Relationship

Authorization

I (we) are the parent(s) or legal guardian(s) of the student listed above and grant my (our) permission for him/her to participate fully in MovementChurch.online events and activities. I (we) understand that MovementChurch.online staff and volunteers will make every attempt to contact me as soon as possible in the event an emergency arises. If I cannot be reached, I (we) authorize MovementChurch.online staff and volunteers to take my I (we) understand that our child may be photographed or videotaped during activities and that these photos/videos may be used in promotional materials published by MovementChurch.online. Authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.

Medical Insurance Company

Policy #/Medical Record #

List any physical disabilities, condition and/or allergies we may need to be aware of:

List any medications, which your child uses:

Liability Waiver

We (I), on behalf of my (our) child, assume the risk and promise to release, forever discharge and hold harmless MovementChurch.online, it's directors, staff and volunteers from any and all liability, claims or demands for personal injury, sickness or dea We (I) also agree to hold harmless and indemnify said church, it's directors, employees and agents, for any liability sustained by said church as a result of the negligent, willful or intentional acts of said participant We (I) hereby certify that we (I) have read and clearly understand these terms and that this authorization/waiver is being executed voluntarily.

Parent/Legal Gardian Signature

This address will receive a confirmation email

Full Name ex: /John Doe/

Today's Date

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Movement Youth Retreat Registration

Description

Please Fix the Following