EPIC LIFE CHURCH - PARENT PERMISSION & RELEASE OF LIABILITY
Student’s Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Student’s Email *
Student’s Cell#: *
Grade for Fall: *
Write the names of 2 people whom you would like to share a bunk bed with. If no preferences, please leave blank:

(Note: This is not a guarantee but preferences will be considered.)
 *
Parent's Name: *
Parent's Email: *
Address: *
City/State/Zip *
Cell Phone: *
Home or Work Phone: *
Emergency Contact #1    Name  -  Phone Number: *
Emergency Contact #2   Name  -  Phone Number: *
List any medical conditions here: *
Insurance Carrier   -   Policy #                                                                                           *
Primary Care Doctor Name   -   Clinic Phone Number                                                                                           *
Parental Consent: *
(I) (We), the undersigned, parent(s) of the minor student listed, do hereby consent to said minor participating in Summer Camp 2022 conducted by Epic Life Church in partnership with Black Lake Bible Camp.  
Authorization of Consent to Treatment of a Minor: *
(I) (We), the undersigned, parent(s) of the Minor, do hereby authorize Epic Life Church, hereinafter “Agent”, for and on behalf of the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis is rendered at the office of said physician or at a hospital, during all times that the Minor is in the presence of said Agent. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization shall remain effective through the 31st day of July, 2022, unless sooner terminated in writing.    
Release of Epic Life Church: *
(I) (We), the undersigned, parent(s) of the Minor, shall indemnify, hold free and harmless, assume liability for and defend Epic Life Church, its agents, servants, employees, officers and directors from any and all liability for personal injury or property damage and costs and expenses including but not limited to, attorney’s fee, reasonable investigative and discovery costs, court costs, and all other sums for any claim or action founded thereon, arising or alleged to have arisen out of the Minor's use of the real or personal property belonging to or used by Agent while Minor is in the presence of Agent.
Signature (Completed Name & Date): *
(I), the undersigned, parent of the minor student listed on this google form, do hereby consent that by typing my name below I agree that this document, to be delivered electronically signed, shall have the same legal validity and enforceability as a manually executed signature. 


Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Epic Life Church. Report Abuse
Google Forms