Retreat/Convention Registration

Sr. High Retreat Jr. High Retreat Youth Convention

(Please mark which event you are registering for.)

Parent Permission & Release Information

Full name Age Birth Date

Year in school [] Male [] Female Email:

Address City State Zip Code

Medical Insurance Company: Policy#

Mother’s name: Phone: Work:

Father’s name: Phone: Work:

Emergency Contact #1 Phone: Work:

Emergency Contact #2 Phone: Work:

I/We the undersigned have legal custody of the student named above, a minor, and have given consent for him/her to attend events being organized by American Baptist Churches, NE. I/We understand that there are inherent risks involved in any ministry or event, and hereby release/ABC/NE, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to persons or property that may occur during the course of our/my child’s involvement. In the event that he/she is injured and requires medical treatment I/We understand that ABC/NE will attempt to contact a parent/emergency contact first for direction in care but if not able to contact I/We authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. I/We alone shall be liable and agree(s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary to have a child return home due to medical reasons or otherwise (behavioral), the undersigned shall assume all transportation costs. I/We also hereby give permission for our child to ride in any vehicle driven by an adult (25 years or older) in whose care the minor has been entrusted while attending and participating in activities. I/We give permission for any photos taken during retreats/convention to be used for publicity.

Parent/Legal guardian signature: Date

(Office use only)

Deposit: Paid in full:

Paid Cash: Paid Check: #

Note:

Student Information

(Please fill out completely)

Full name Sponsoring Church:

Circle the following areas of concern for this student and explain (use additional paper if needed)

Current Medications: Date of last tetanus shot:

Allergies to: Food Medicines Insect bites Pollen

Explain/Other:

Concerns/Limitations: Swimming Physical limitations Major illness/surgeries in the last year

Explain/Other:

Does your child have any history of/or currently being treated for:

Asthma seizure disorder heart trouble diabetes

Explain/Other:

I, the student, have read the rules of conduct and agree to abide by these rules. I understand that if I do not follow this agreement, I can and will be sent home. If sent home, it will be at my parent’s expense.

Student’s signature: Date: