Name of Teen________________________________Age_____Grade_____Birthdate_________________

Name of Teen________________________________Age_____Grade______ Birthdate________________

Name of Teen________________________________Age_____Grade______ Birthdate________________

Parent/Guardian Contact Name and Phone________________________________/_________________

Address _______________________________ City _________________ State ___ Zip __________

Email address: ________________________________________________________________________

Would you like to receive email notices of calendar events for all LifeWay Youth Events Yes or No

Emergency Contact Name & Number _____________________________________________________

(If parents are unavailable)

Does your youth have medical insurance yes or no(please circle)

Insurance Information (Company and Policy #) _____________________________________________

Medical Information

Please list any allergies medications, medical information, or chronic illnesses your student may have. Please write “NONE” if there is not special circumstances/information/medication that we need to be aware of.

General Release and Hold Harmless Agreement

The undersigned, being the legal guardian of participants listed above give permission for my youth to attend in full all the events on site at LifeWay Church and off site that is not an overnight stay. You, being the legal guardian of participant, hereby give your permission for LifeWay to take said participant to a doctor or hospital; you also hereby authorize the medical treatment of the participant, including transportation to and from LifeWay Church. You further authorize treatment by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life and/or cause disfigurement, physical impairment, or undue discomfort if delayed. You will assume responsibility of all medical bills, if any.

This authority is granted only after a reasonable attempt has been made to contact you. You understand and acknowledge that the Church would not allow the participant to participate in such activity without releasing and holding harmless the Church. Further, in consideration of the church allowing your youth to participate in the activity, you agree to release and forever discharge the Church, their officers and directors, their employees and their agents, and any parties volunteering on behalf of the Church from all actions, claims, costs, expenses or damages of any kind growing out of or related to this activity and the participant.

__________________________________________________________Date___________________

Printed Name of Parent / Legal Guardian

__________________________________________________________ Date___________________

Signature of Parent/Legal Guardian

Photos and video release! Do you give permission for LifeWay Church to use your youth’s image and name associated with any online or in print marketing for LifeWay Church? YES or NO (circle) ______________________________________________ (Sign Here)