Please Complete the Form Below to Confirm Your Child’s Participation in “EXTRA CONFERENCE 2018!”


CHILD'S INFORMATION



Age

PARENT'S INFORMATION



EMERGENCY CONTACT / INFORMATION



FOOD ALLERGIES

If YES, please explain in complete detail:

MEDICAL CONCERNS

If YES, please explain in complete detail:

FAMILY DOCTOR

SIBLINGS ATTENDING CONFERENCE?

If YES, please list their names and ages:

PLEASE STATE YOUR CHURCH AFFILIATION

ARE YOU A MEMBER AT ANOTHER CHURCH?

IF YES, PLEASE LET US KNOW WHERE

PEOPLE WHO MAY PICK UP MY CHILD:

NUMBER OF DAYS ATTENDING CONFERENCE
123

T-SHIRT SIZE

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.