All-Nighter Registration

ALL-NIGHTER REGISTRATION FORM

Date: Feb 17th 9pm-Feb 18th 6am
Location: Church and Surrounding Location

* Indicates required field

Students Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Gender *

Grade *

Email *

Parental Information *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Emergency Contact Name *

Relation to Child *

Emergency Phone # *

Permission and Release

I give permission for my child to participate in this activity. In the
event he/she is injured, I waive and release all rights to any claim for
damages against the sponsor or its representatives. I further agree
that any claim or dispute arising from or related to this
agreement shall be settled by mediation and, if necessary, legally
binding arbitration, in accordance with the Rules of the Institute for
Christian Conciliation; judgment upon an arbitration award may be
entered in any court otherwise having jurisdiction. In the event
disciplinary action need to be taken against my child due to
inappropriate behavior or misconduct, I understand that any
expenses incurred will be the responsibility of the parent or guardian
of the child.

Medical Release

In the event my child suffers sudden illness, accident, or injury and
neither parents nor guardians can be contacted, I give permission for
any emergency treatment that is deemed necessary by a licensed
physician. I assume responsibility for costs connected to accident/treatment of the child.

Medical and Insurance Information

Family Physician Office Phone # *

Insurance Company *

Pertinent Medical Info (Diabetes, Allergies, Etc.) *

Media Release

I grant permission to North Rome Wesleyan Church to take images/videos of my child during this activity for the sole purpose of training, promotions and publications including Facebook postings, and waive any rights of compensation. I understand that my child/children’s names will not be published with the image.

Media Release *

Yes, I give Permission No, I do not give Permission

Other Comment *

Submit