2018 Fellowship Students Winter Retreat: December 7-9

Student Information

Student's Name

Address

Date of Birth

Grade

Student's Phone #

T-Shirt Size

Small Medium Large X-Large XX-Large

Parent Information

Parent's Name

Parent's Phone

Parent's Email

Medical Information

Primary Care Physician

Physician's Phone #

Insurance Provider

Policy #

Does your student have any condition or illness that would prevent their full participation in any physical activity?

Yes No

If yes, please explain

Does your student have any food related allergies?

Yes No

If yes, please explain

Is your student dependent on an albuterol or rescue inhaler?

Yes No

Does your student have any of the following conditions?

Asthma Heart Murmurs Epilepsy Kidney Problems Chronic Back Pain None

If your student takes medications, is he/she able to manage his/her own medication?

Yes No N/A

Release & Waiver

I give consent for my student to participate in the 2018 Winter Retreat with Fellowship Church and Cedar Creek Baptist Church. I do not hold Fellowship or CCBC volunteers, associates, or any of their subsidiaries liable for any injuries, accidents, or illnesses incurred during the event.

I understand I am responsible for the expenses of my student’s medical care and that my family insurance is primary.

I further give my consent for my child to ride in any vehicle the sponsors may designate.

I understand that I am responsible for my child’s transportation to and from the location of the event, even though Fellowship has provided transportation.

I also give my permission for my student’s photo to be used in Fellowship and/or CCBC flyers, their websites, or advertisements produced by Fellowship and/or CCBC.

I have read the release and give my student permission to participate in the Winter Retreat.

Yes

Electronic Signature

Payment $35.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2018 Fellowship Students Winter Retreat: December 7-9

Description

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