NPWC TEEN CAMP REGISTRATION

 
Parent Name *
Parent Name
Phone *
Phone
Address *
Address
Participant Name *
Participant Name
Birth Date *
Birth Date
I give permission for my child (named above) to attend the events, fellowships, field trips, outreaches and service projects associated with the North Pole Worship Center Youth Group of North Pole, Alaska. I further give permission for my child to be transported to and from events by hired and volunteer drivers authorized by North Pole Worship Center. Medical Release I hereby authorize the North Pole Worship Center Youth Group leaders, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child. Custody Release I further authorize the North Pole Worship Center Youth Group leaders to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult. Activity Release I further give permission for my child to participate in all supervised activities except as noted: Liability Waiver For value received, I represent that I am a custodial parent of child (*named above) and agree on behalf of myself, and the child’s other parent (list other parent’s full name BELOW if know or living), my child named herein, our heirs, successors, and assigns, to forever release, discharge, defend and hold harmless North Pole Worship Center, any of its employees (paid or volunteer) or chaperons, from any and all liability, claim, loss, damage, cost or expense that may be mad or brought on my behalf or on my child’s other parent’s behalf, or on my child’s behalf against North Pole Worship Center, and any of their partner ministries, or any of its employees (paid or volunteer) or chaperones. I forever waive any such claims against any such person or organization arising directly or indirectly from, or attributable in any legal way, to any action or omission to act of any such person or organization named above. I fully understand the consequence of the foregoing statements and sign this PARENTAL/GUARDIAN Permission and Medical Authorization Form knowingly, freely, and willingly.
Other Parent
Other Parent
Emergency Contact Information
Address *
Address
Phone 1 *
Phone 1
Phone 2
Phone 2
Health Care Information
Physician Name
Physician Name
Phone
Phone
Name of Policy Holder
Name of Policy Holder
Information Provided on this form will be kept strictly confidential.