JOURNEY MEDICAL RELEASE/PERMISSION SLIP FOR RIPTIDE WINTER CAMP 2012 

Please complete the form below to register:

Participant's Name (first & last)	*
Participant's Grade in Fall 2012		6th Grade 7th Grade 8th Grade
Participant's School in Fall 2011	*
Gender	*	Female Male
Participant's Birthday (month/date/year)	*
Participant's Address	*
City	*
State	*	- - Choose One - - Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip	*
Parent/Guardian Name	*
Parent Email Address	*
Parent Cell Phone	*
Home Phone	*
Medical Information
Health Insurance Provider	*
Policy Number
Physician's Name
Allergies, Known Medical Conditions, Current Medications
Emergency Contact	*
Emergency Contact Phone	*
Please read and enter your name below as your digital signature: I/We, the undersigned parent(s)/legal guardian(s) of the above minor (s), do hereby release and agree to hold harmless Journey Community Church and any related member, employee, sponsor or agent from any liability, injury, damages, loss, accidents, delay, or irregularity related to the listed minor’s planned participation in Journey Community Church sponsored events occurring on July 31, 2012 through August 4, 2012. This release covers all rights and actions of every kind, nature, and description, which the minor and his/her parent(s)/legal guardian(s) ever had, now has, or but for the release, may have.
Digital Signature of Parent/Legal Guardian	*
Date	*