Fall Retreat

Child Attending Name *

First Name

Last Name

Parent/Guardian Name *

Name of parent or guardian responsible for Child. You will be the one referred to in the waiver below.

First Name

Last Name

Your Phone Number *

In case of emergency

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Liability Release and/or Consent To Travel *

I, the parent or guardian named above, being the parent/legal guardian of the minor named above, do hereby release, OLD TOWN CHRISTIAN OUTREACH CENTER, its agents, assigns, employees, and volunteer assistants from any liability whatsoever arising out of injury, sickness, damage, or death, which may be sustained by the minor named above during the course of the above stated event, ministry, or any related activities for this trip.

I Agree

Medical Release *

I, the parent or legal guardian name above, being the parent/legal guardian of the minor named above, do hereby give my consent for the director or properly appointed staff member of OLD TOWN CHRISTIAN OUTREACH CENTER and do further agree to the performance of such treatment, anesthetic, and operations as in the opinion of the attending physician is deemed necessary for the above name minor. I also agree to pay for performance of such treatment, anesthetics, and operations as deemed necessary in the opinion of the attending physician.

I Agree

Disciplinary Agreement *

I, the parent or legal guardian name above, being the parent/legal guardian of the minor named above, understand that while the minor named above participates in this event, is responsible to abide by the rules set forth by the sponsoring organization, its leaders, and the supervisory personnel. Any unacceptable conduct or infraction of rule and/or conduct by the minor named above agree to assume the cost of returning home. I the guardian agree to come and pick up child early if necessary due to infraction of rule and/or conduct by the minor named above.

I Agree

Parent Guardian Acknowledgment *

I the above named parent or legal guardian agree have read and agree to the above liability, medical release, and disciplinary agreement.

Yes, I have read and agree to the above form.