LRC Students 2020

Name of Parent or Legal Guardian

Named of Second Parent or Legal Guardian

This address will receive a confirmation email

Phone

Address

STUDENT INFORMATION

Student #1

Name

Grade

Birthdate

Allergies or Special Instructions

Student #2 (If Applicable)

Name

Grade

Birthdate

Allergies or Special Instructions

Student #3 (If Applicable)

Name

Grade

Birthdate

Allergies or Special Instructions

Student #4 (If Applicable)

Name

Grade

Birthdate

Allergies or Special Instructions

Medical Release

Emergency Contact Name

Emergency Contact Number

Primary Physician's Name

Primary Physician's Number

Is/are your student(s) covered by personal/family medical insurance?

Yes No

If yes, name of insurer:

Policy or group number:

Medical Release and Participation Agreement

1. I/We, the undersigned have legal custody of the student(s) named above, a minor/minors, and give our consent for them to attend and participate in events and activities being organized by Living Rock Church Student Ministry. I/We acknowledge that participation in LRC events and activities involves risk to the student(s) (and to the student's parent(s) or legal guardian(s), if the student is a minor), and may result in various types of injury including, but not limited to, the folowing: sickness, exposure to infectious/communicable diesease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

2. In consideration for the opportunity to participate in LRC Student Ministry events and activities, I/We acknowledge and accept the risks of injury associated with participation in and transportation to and from all events and activities. I/We accept personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the student that is authorized by Living Rock Church or its agents, employees, volunteers, or any other representatives.

3. Further, I/We agree to assume financial responsibility due to property damage/loss caused by student(s) and travel cost if student(s) should they become ill or fail to comply with the stated rules of conduct which are as follows:

The model for all conduct and attitudes is the Lord Jesus Christ

Avoid all questionable activity and things which would be offensive to Christ, family, and Living Rock Church
No possession or use of alcohol, drugs, or tobacco
No student or leader can transport other youth in a vehicle without parental consent
No fighting, weapons, fireworks, lighters, or explosives
No inappropriate behavior with the opposite sex (including but not limited to hand holding or suggestive comments)
Respect one another, staff, and adult leaders
Respect property
Damage or vandalism to property of others will become the responsibility of the participant
Participation with the group is expected
Respect and comply with event schedules

Indicate that you have read the above and agree by selecting

I have read and agree. I do NOT agree.

Parent or Legal Guardian Name as Signature

2nd Parent or Legal Guardian Name as Signature

Photo Release: Living Rock Church occasionally has the opportunity to use photos to promote our student ministry. Uses might include a display board, slide show, pamphlet, church website, social media page, press release or newsletter.

Yes, I approve of using photos of my student(s). No, I do not approve of using photos of my student(s).

All our students will be working through a year-long Bible study book together. You can pay online now or later in-person.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

LRC Students 2020

Description

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