FELLOWSHIP BIBLE CHURCHPreTeen Retreat >> STUDENT SIGNUP FORM

Child First Name: ___________________________

Gender: M F

Grade: ____

Child Last Name: ________________________________

Age: ____

Birthdate: __ / __ / ____
MM / DD /

Address: ____________________________________

YYYY

City: ______________________ State: ___ Zip: ___________

Allergies: ________________________________________________________________________________
Medical: _________________________________________________________________________________
Behavioral/Social/Environmental: _____________________________________________________________
Shirt Size: ___________

Cost: $70/kid

Paid: Cash_______ Check ______

Parent/Guardian #1 (Authorized to Pick Up Child)

First Name: ____________________ Last Name: ______________________

Email: ___________________________

Cell Phone: (

) - ______ - _______

) - ______ - _______

Tex.ng: Y N

Other Phone: (

Tex.ng: Y N

Parent/Guardian #2 (Authorized to Pick Up Child)

First Name: ____________________ Last Name: ______________________

Email: ___________________________

Cell Phone: (

) - ______ - _______

) - ______ - _______

Tex.ng: Y N

Other Phone: (

Tex.ng: Y N

Insurance Carrier: ____________________ Policy Number: ________________________ Phone: _________________

Cell Phone: (

) - ______ - __________

Other Phone: (

) - ______ - __________

EMERGENCY CONTACT (Not Listed Above, But Authorized to Pick Up Child)

First Name: __________________________________
Cell Phone: (

) - ______ - __________

Last Name: _______________________________

Other Phone: (

) - ______ - __________

Emergency Contact Rela.onship: ______________________________________________________________

FELLOWSHIP BIBLE CHURCH ACTIVITY CONSENT/RELEASE & PHOTOGRAPHIC RELEASE FOR MINORS
Please note that we will be taking photos and videos of the ac4vi4es throughout the event. We use the photos and videos only for church related purposes, including posts to the Fellowship Bible Church website, social media, brochures, etc. If you wish to exclude your child(ren) from the photos and videos, please speak with
a FellowshipKids Team Member. By signing below, I give Fellowship Bible Church permission to publish in print, electronic, website, or video format the likeness or
image of my child. I release all claims against Fellowship Bible Church with respect to copyright, ownership, and publica.on, including any claim for compensa.on
related to use of the materials. I, the undersigned parent or guardian, hereby consent to my child par.cipa.ng in the ac.vi.es connected with PreTeen Retreat on
February 26 & 27, 2016 and that my child is able to par.cipate in all ac.vi.es scheduled for this event. If my child has medical condi.ons which may be
relevant to a physician in the event of an emergency, I have listed them above. I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE
ENCOUNTERED DURING SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold Fellowship Bible Church and
their agents, volunteers and employees, harmless from any and all liability, ac.ons, causes, claims, expenses, and damages on account of injury to my child or property, even injury resul.ng in death, which I now have or which may arise in the future in connec.on with the ac.vity or par.cipa.on in any other associated ac.vi.es. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permiAed by the law of the State of Oklahoma
and that if any por.on thereof is held invalid, it is agreed that the balance shall, notwithstanding, con.nue in full legal force and eect. This release contains the
en.re agreement between par.es hereto, and the terms of this release are contractual and not a mere recital. I further state that I HAVE CAREFULLY READ THE
FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read
and understand.
Signature of Parent/Guardian _________________________________________________________________________________ Date _______________________