REGISTER YOUR STUDENT FOR LH/PM

SM REGISTRATION FORM

Student's Name

First Name

Last Name

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Parent/Guardian Name

First Name

Last Name

Emergency Contact Number

Medical Insurance Carrier

Policy Number

Name on Insurance Card

Please list allergies and/or other medical information we should know.

I hereby give my permission for myself or my child to participate in an activity organized by Living Hope Church. I hereby release, hold harmless and absolve Living Hope Church, their staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Living Hope Church staff or any adult counselor acting on behalf of Living Hope Church with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child’s medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that Living Hope Church may tape or photograph my child and record his or her voice during their participation in the activity. I agree that Living Hope Church will be able to use them, in whole or in part, whether in original or modified form in any manner or media, including without limitation, for the purpose of advertising, promoting, and publicizing Living Hope Church, whether during the activity or thereafter. I hereby release and discharge Living Hope Church and all affiliated entities from any and all claims, demands, or causes of action that I have in connection with the use and exercise of the rights granted in this release. PHOTOGRAPH RELEASE FORM LH Student Ministry and Living Hope Church Events I grant to Living Hope Church, its representatives and employees the right to take photographs of my student in connection with Living Hope Church. I agree that Living Hope Church may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. I have read and understand the above:

Date

MM

DD

YYYY

BACK TO LH/STUDENTS