3830 N. 67th Avenue Phoenix, AZ 85033 Phone: 623-849-2363 PERMISSION SLIP/HEALTH FORM, LIABILITY RELEASE Activity: Youth For Christ (YFC) Summer Camp Where: 27224 Hwy 78, Ramona, California, 92065 When: July 26 - August 1 STUDENT INFORMATION Student Name _________________________________________________________ Phone _________________________________ Grade ______________________ Date of Birth _______/_______/_______ Address _______________________________________ City ____________________ State __________ Zip Code ________________ Parent or Legal Guardian _______________________________________________________ Relationship ______________________ Phone ________________________________ Email _________________________________________________________________ Emergency Contact ______________________________________________________ Phone ________________________________ Emergency Contact ______________________________________________________ Phone ________________________________ INSURANCE AND MEDICAL INFORMATION Do you have medical insurance? Yes ____ No ____ If yes, please complete the following: Your Insurance Carrier _______________________ Policy Number/Group Number ___________________________ If no, I acknowledge that I do not have medical insurance and relinquish CATALYST CHURCH from any liability. Signature ______________________________________________________________________ Date_________________________ If your child has any medical conditions/ medication/ food allergies that we need to know about, please list _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Page 1 of 2 PARENTAL CONSENT Waiver and release In consideration of my child’s participation in the activities of CATALYST CHURCH , I ______________________________, hereby, for myself, my heirs, executors, administrators and assigns, release, waive and/or forever discharge any and all rights and claims for damages that may be suﬀered by my child as a result of his/her preparation for, participation in or traveling to or from the activities. I recognize the risks associated with my child’s participation in the activities and speciﬁcally agree to indemnify and hold harmless CATALYST CHURCH, including any members of the governing body and any Promoter, sponsors, or subcontractors whose facilities and/or services are being used for these activities, from any and all injuries or damages arising from or in any way contributed to the subject of this forms participation in these activities. Parents must approve the waiver for their children under the age of 18 years. I, the parent, guardian or legal custodian of the above named participant do hereby assent to the above waiver and release and agree to all terms as stated above. Initial _____________ I, who by law may do so, authorize the administration of emergency medical treatment to he/she who is the Subject of this form. I understand all reasonable safety precautions will be taken at all times by CATALYST CHURCH or its agents for any accident, injury or disease incurred by the subject of this form. I understand that in the event medical intervention is needed every attempt will be made to contact the person(s) below immediately. Initial _____________ Photograph Release I hereby authorize CATALYST CHURCH to take photos and to publish photographs taken of _________________________ (student) during the Fireproof outing. Photos may be used to promote Fireproof through CATALYST CHURCH media, I hereby release and hold harmless CATALYST CHURCH from any reasonable expectation of privacy or conﬁdentiality associated with the images speciﬁed above. I further acknowledge that my participation is voluntary and that I will not receive ﬁnancial compensation of any type associated with the talking or publication of these photographs or participation In CATALYST CHURCH materials. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever. I hereby release CATALYST CHURCH, its employees, and any third parties involved in the creation or publication of materials, form liability for any claims by me or any third party in connection with participation. Printed Name _________________________________________________ Signature _____________________________________________________ Page 2 of 2 Date ______________________