YOUTH EVENT RELEASE FORM Parent / Guardian's Name * Phone * (###) ### #### Email Child #1: Name * First Name Last Name Child #1: Age * Click here to select age 12 years 13 years 14 years 15 years 16 years 17 years Allergies / Medical Conditions * Does your child have a food or environmental allergy, diagnosed medical condition, learning disability, or anything other condition we should be aware of? Yes No If you selected "Yes" to the last question, please explain. NOTE: LETOURNEAU IS ONLY ABLE TO ACCOMMODATE FOR GLUTEN FOOD ALLERGIES. Child #2: Name First Name Last Name Child #2: Age Click here to select age 12 years 13 years 14 years 15 years 16 years 17 years Allergies / Medical Conditions Does your child have a food or environmental allergy, diagnosed medical condition, learning disability, or anything other condition we should be aware of? Yes No If you selected "Yes" to the last question, please explain. NOTE: LETOURNEAU IS ONLY ABLE TO ACCOMMODATE FOR GLUTEN FOOD ALLERGIES. Child #3: Name First Name Last Name Child #3: Age Click here to select age 12 years 13 years 14 years 15 years 16 years 17 years Allergies / Medical Conditions Does your child have a food or environmental allergy, diagnosed medical condition, learning disability, or anything other condition we should be aware of? Yes No If you selected "Yes" to the last question, please explain. NOTE: LETOURNEAU IS ONLY ABLE TO ACCOMMODATE FOR GLUTEN FOOD ALLERGIES. Emergency Contact * In the event of an emergency, we will first contact the Parent/Guardian listed above. If we are unable to get in contact with them, please list a second contact below. First Name Last Name Phone * (###) ### #### Relationship to Child(ren) * MEDICAL TREATMENT: In the event on an emergency, I hereby consent and authorize permission for emergency medical treatment for my child(ren) listed above. I agree to release Calvary Chapel Center City, its leaders, employees, or event volunteer staff, from any liability for any injuries incurred. * Select One Yes No I GIVE MY PERMISSION TO CALVARY CHAPEL CENTER CITY TO DRIVE MY CHILD(REN) TO AND FROM CALVARY CHAPEL CENTER CITY’S YOUTH EVENTS. I agree to relate Calvary Chapel Center City, it's leaders, employees, volunteers, and all youth event chaperones or drivers from any liability for any damages, losses, or injuries incured. * Please select one Yes No I authorize Calvary Chapel Center City, the right to take photographs and video of me and/or my child(red) listed above, in connection with Youth Events. I authorize Calvary Chapel Center City, the right to publish the photos / video clips in print, on their website, and social media pages for the purpose of advertisement, recap videos. * Please select one Yes No Thank you for signing the release form for you child to join us! If you have any questions or concerns about the form, speak to Karlee Bendijo.
