Basic Information

Name:

Street:

City:

State:

Zip:

Phone:

Birth Date:

Sex: M     F

email:

Church:

Youth Pastor:

Emergency Contact Information

Contact Name:

Relationship:

Daytime Phone:

Evening Phone:

Insurance Carrier:

Policy Number:

Known Allergies or Medical Conditions:

Parental Consent Form

I, , being the parent/guardian of , understand that while every precaution will be taken to ensure for the welfare and protection of my child, Revival Tabernacle Church, its staff, members, and volunteers, or anyone acting on its behalf, are hereby released from any and all liability in the event of an accident or misfortune, damage or loss that may occur to the students and their property. In the case of a medical emergency, I hereby give permission to the doctor chosen by War Week staff to secure emergency treatment for my child. I understand that every effort will be made to contact me before instituting such procedures. I agree to pay all such doctor, ambulance and hospital fees incurred on behalf of my child. I have listed any health information about my child that the War Week staff needs to know.

Signature:     Date: