Event Registration « : Asylum, We Love Teenagers

Event*

Student Name*

T-Shirt Size ($10)

Parent or Legal Guardian's Name*

Student Address*

Street AddressAddress Line 2CityStateZip Code

Home Phone*

Student Cell Phone

Student Email Address

School They Attend

Lunch Schedule

Grade

Male or Female*

Age*

Date of Birth*

Do you have any medical problems or allergic reactions to any medications?*

LIMITATIONS

Does this student have any physical limitations?*

Has this student had psychiatric treatment?*

Does this camper have mental limitations?*

If Yes, Please explain:*

Make all checks payable to Family Cathedral of Praise or FCOP. Credit Card Information must be correct and good to process registration form.

Name on Card

FirstLast

Address on Billing Statement

Street AddressAddress Line 2CityStateZip Code

Credit Card #

CC Exp Date (##/##)

CC Sec. Code

I affirm that all information above is real and factual*

Yes
No

Minor’s release of claims and hold harmless agreement I, hereby affirm and agree that I am he parent or legal guardian of the child listed above, a minor (“Minor”); that I am legally competent to sign this agreement and release; that I have fully informed myself of this agreement by reading it before signing; and that I have fully informed myself of the details and risks of the Activity prior to signing this release. I agree, individually and on behalf of Minor, to release and to hold harmless Family Cathedral of Praise and Asylum, its agents, officers, directors, and employees (collectively referred to as “the Church”) from liability of any kind, for Minor’s injury, death, or damage to or loss of Minor’s personal property, resulting directly or indirectly from his/her participation in the activity or from the Church’s negligence. I personally assume all risks and liabilities in connection with Minor’s participation in the Activity and agree to indemnify the Church from any liability assessed against the Church as a direct or indirect result of Minor’s participation in the Activity. This release includes all risks and liabilities connected with the Activity, whether foreseen or unforeseen. In the event that Minor is injured during the Activity, and I am unable to provide consent to his or her medical treatment, I authorize the Church to consent on my behalf to the performance of any and all medical treatment judged necessary by the Church, until I am able to provide consent or until some legally able to speak on Minor’s behalf is made available. I agree, individually and on behalf of Minor, to release, indemnify, and hold the Church harmless from any liability which may be assessed against the Church as a direct or indirect result of said medical treatment. I agree to pay or arrange for payment for all costs associated with said medical treatment. By clicking submit, I affirm that all information above is real and factual

I agree to the Minor's release of claims and hold harmless agreement.*

I agree

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