Please Complete the Form Below to Confirm Your Child’s Participation in “EXTRA CONFERENCE 2018!” CHILD'S INFORMATION Age 56789101112 PARENT'S INFORMATION EMERGENCY CONTACT / INFORMATION FOOD ALLERGIES NoYes If YES, please explain in complete detail: MEDICAL CONCERNS NoYes If YES, please explain in complete detail: FAMILY DOCTOR SIBLINGS ATTENDING CONFERENCE? NoYes If YES, please list their names and ages: PLEASE STATE YOUR CHURCH AFFILIATION ARE YOU A MEMBER AT ANOTHER CHURCH? NoYes IF YES, PLEASE LET US KNOW WHERE PEOPLE WHO MAY PICK UP MY CHILD: No one else may pick up my childOnly person(s) listed below may pick up my child NUMBER OF DAYS ATTENDING CONFERENCE 123 T-SHIRT SIZE XSSMLXL AGREEMENT TO PARTICIPATE/ASSUMPTION OF RISK/RELEASE OF LIABILITY (Please Read Before Signing) I/we acknowledge that during the session the applicant is participating in, certain risks and danger may occur. I/we recognize that such risks and danger include loss or damage to personal property, physical injury or fatality due to an accident. I/my child is healthy (both physically and mentally) and capable of participating in the session. The above health history is correct as far as I/we know, and the person herein described has permission to engage in all prescribed conference activities except as noted. In the event the parent or guardian cannot be reached in an emergency, I/we hereby give permission to the physician selected by the conference director to secure and administer treatment, including hospitalization, for me/my child as necessary. I, individually and on behalf of the minor, do hereby release New Heights Church and its conference staff from any and all liability. I also understand that my/my child's participation in this conference program is entirely VOLUNTARY. I/my child enters into this session and take all responsibility for my decisions to participate or not to participate, and agree to follow all safety instructions. I understand that photographs or videos may be taken of me/my child during this session for promotional use for New Heights Church. I understand that I will not receive compensation, monetary or otherwise in exchange for the images. I agree that being allowed to participate in the conference is sufficient consideration to support this agreement to participate. *CONFIRMATION - BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING 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.