Youth's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Youth Phone

(###)

###

####

Name of Parent/Legal Guardian *

with whom you live

First Name

Last Name

Parent Phone *

(###)

###

####

Youth's Doctor's Name

First Name

Last Name

Doctor's Phone

(###)

###

####

Person to notify in the event you cannot be reached *

First Name

Last Name

Phone *

(###)

###

####

Parent Signature: I, the parent or legal guardian of the student listed on the form, certify that he/she has my full approval to participate in Central Christian Church youth events. The child identified on this form understands that all students are expected to abide by the rules and be directly responsible to the Youth Staff. Central Christian Church Youth Staff assumes responsibility for discipline at the event and, if necessary, may, because of misconduct or disobedience, require a student to leave. In such instance, I will assume full responsibility for returning the student home. Further, I do release and hereby agree to hold blameless Central Christian Church and its employees and agents from any and every claim arising, or which may be asserted by me or by any member of my family by reason of participating in any activities associated with Central Christian Church. I also release the lessor of properties on which the event is held. Further, I do authorize the minister or sponsor of this activity or any Central Christian Church staff member, in the event I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while on this trip. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment. Further, I give Central Christian Church permission to use photo and video taken at Central Christian Church events in promotional materials. Further, I do certify that said child is covered by adequate accident insurance. My consent and signature is given below. I have read and agree to the information given in this entire form. *

First Name

Last Name