WKND Fall Retreat

Child 1 Name *

First Name Last Name

Child 2 Name

First Name Last Name

Parent's Name *

First Name Last Name

Parent's Phone Number *

Area Code Phone Number

Student's Insurance Policy Number *

Group Number *

Insurance Carrier *

Student's Doctor Name *

Student's Doctor Phone Number *

Area Code Phone Number

Allergies/ Medical Conditions

By signing this form I give permission for my child(ren) to participate in the WKND Fall Retreat with HC Youth.

I also certify that photographs or videos of my student participating in any Heritage Church sponsored program and/or activity may be reproduced and utilized in promotional materials for the church. I understand that Heritage Church will not release my student’s name or other personal information.

I further give my permission for Heritage Church, its employees and volunteers to obtain any medical care deemed necessary for my child by an accredited physician, nurse or hospital.

I also give permission for my student to ride in any vehicle driven by an approved ADULT chaperone or a transportation company while attending and participating in activities sponsored by the Church. My child and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation.

If I cannot be reached in the event of an emergency please contact the following person:

Emergency Contact *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

I/we also agree to hold harmless, indemnify and defend Heritage Church, its employees and volunteers against injury, claim or action that may arise on behalf of my son or daughter other than for the willful or reckless misconduct of Heritage Church, its employees or volunteers. The parent(s) and/ or guardian(s) understands and agrees that this Registration Form is of a continuing nature and shall be interpreted in its broadest form to permit the students to participate in all student activities sponsored by Heritage Church, including, but not limited to, transportation. The parent(s) and/ or guardian(s) may rescind this Registration Form at any time but said rescission shall be effective only upon receipt by Heritage Church of the parent(s) and / or guardian(s) rescission in writing. Please direct any such written communications to 44625 Schoenherr Road, Sterling Heights, Michigan 48313.

Parent/Guardian Signature *

Clear

the WKND 2019 Permission Form