THE SIGN UP Student Name * Name of the young human who will be attending First Name Last Name Student or Parent Email Student DOB * When was you borned? MM DD YYYY Grade * What skool grade you in? 6 7 8 9 10 11 12 13? Student Phone What's yo digits? (###) ### #### Parent/Guardian Name * Who do we call if you aren't nice? First Name Last Name Parent/Guardian Phone * What do we dial to talk to your adult? (###) ### #### Known Allergies or Medical Conditions Let us know how to keep you alive Prescribed Medications ...to let the drug dogs know Informed Consent and Acknowledgement * Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Covenant Life Youth Ministry during the selected event. In exchange for the acceptance of said child’s candidacy by Covenant Life Youth Ministry, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Covenant Life Youth Ministry and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected retreat/camp sessions. In case of injury to said child, I hereby waive all claims against Covenant Life Youth Ministry including all Directors, Coaches, Team Parents and affiliates, all participants, sponsoring agencies, advertisers; and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all outdoor or adventure activities. Some of these injuries include but are not limited to, the risk of fractures, paralysis, or death. Medical Release and Authorization As Parent and/or Guardian of the above named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Covenant Life Youth Ministry and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. Yes I acknowledge and consent to my child's participation Nope ConfirmationBY ACKNOWLEDGING SUBMITTING THIS FORM, I SUBMITTING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
