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Parent or Guardian (1) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Parent or Guardian (2) - Optional

First Name

Last Name

Phone (2) - Optional

(###)

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Does your family currently attend a church? - Optional

Yes

No

Liability and Emergency Medical Release: I hereby release and authorize the adults or other individuals participating and assisting in this activity to act for me according to their best judgment in any emergency requiring medical or dental attention for my child. I further agree to pay all costs and expenses incurred in connection with such medical and dental services. Should it become necessary for our (my) child to return home due to medical reasons or otherwise, I agree to pay all costs associated with that return. Furthermore, I hereby release, discharge, and hold harmless all adults or other individuals participating and assisting in this activity or in the transportation incident thereto, Journey Christian Church, its members, agents, employees, and officers, from all claims, demands, actions, judgments, and executions which I, my heirs, executors, administrators, or assigns may have, or claim to have, against the above, their successors and/or assigns, for all personal injuries, known or unknown, and injuries to property, real or personal, caused or arising out of, the above described activity or related thereto. *

YES

NO

I give consent for my child to have his/her photo or video taken for the sole purpose of promoting similar activities of Journey Christian Church and to celebrate together the fun that is had. *

YES

NO