The Great Escape Registration

Student Name

First Name Last Name

Grade Level for 2020-2021 School Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Gender

Male Female

Emergency Contact

First Name Last Name

Emergency Contact Relationship

Emergency Contact Phone

Area Code Phone Number

Insurance Provider and Policy Number

By Signing this you acknowledge that you have read the terms and conditions. The undersigned does hereby give permission for my child, to attend and participate in activities sponsored by Grace Evangelical Free Church for the date of June 15th - June 19th 2020. I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examinations, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Grace Evangelical Free Church. By also signing this document, the undersigned gives permission for my child’s likeness in the form of still picture and/or video and audio to be used in any church sponsored promotional material.

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