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24Seven – 2010 Event Release Form

Church on the Word, Inc. | 8016 W. Camelback Rd | Glendale, AZ 85303 The following form must be completed for each student 18 years of age or younger who wishes to participate in any Church on the Word sponsored Program. (Please print clearly) General Information Students Name: _____________________________________________________________________ Gender:  M

F

Address: ____________________________________________________________________________ Apt#: _____________ City: _______________________________________________________________ State: ______ Zip Code: _____________ Home Phone: (______) __________________________ Cell Phone: (______) ___________________________ Birth Date: ______/______/______

Grade: ________

Name of Parents or Legal Guardians: _______________________________________________________________________ Contact Phone: (______) ___________________________ Emergency Contact: _________________________________________________ Relationship: _______________________ Phone1: (______) ___________________________ Phone2: (______) ___________________________ Authorized Individuals The following individuals have my authorization to pick-up the student from Program. Name: _____________________________________________________________ Relationship: _______________________ Name: _____________________________________________________________ Relationship: _______________________ Insurance Coverage Information Insurance carrier: ___________________________________________________ Policy #: ___________________________ Insurance carrier phone number: (______) ___________________________

 Please check if NO insurance coverage exists. I, the parent or legal guardian of the student listed on this form, certify that he/she has my full approval to participate in the activity or event, hereafter referred to as (“Program”) associated with Church On The Word, Inc., hereafter referred to as (“COTW”). Program Information 24Seven Ministry Holiday Party (Peter Piper Pizza and Jump Street) located 51st Ave. & Bell Rd. Friday December17, 2010 from 5:15PM – 10:30PM, cost of this event will be $20.00 Times are approximate. Acknowledgement of Risks I acknowledge that there are certain risks associated with the Program, including, but not limited to, loss or damaged personal/public property, physical injury, illness, or even death. I verify that student is in good health with no known serious medical conditions and is capable of handling the physical and mental demands of Program. I assume full financial responsibility for any bodily injuries, accidents, illness, death, loss of personal property, and expenses thereof as a result of any accident/injury, administration of medication or first aid that may occur from participation in Program. Transportation Release I give my consent for the student listed on this form to be transported to and from any COTW Program, if necessary. I further understand that at times personal vehicles or COTW staff and or volunteers may be used.


Medical Treatment Release I authorize the COTW staff or sponsoring volunteer of this Program, in the event that I cannot be reached, to give consent to a physician and/or hospital for emergency medical or surgical treatment to my child. I authorize the COTW staff or sponsoring volunteer of this Program to administer over-the-counter and routine medications to my child. Furthermore, it is understood and agreed that I will assume full financial responsibility for any expenses (including the reimbursement of payment by COTW staff or sponsoring volunteer of this Program) that may be incurred for said medical or medication treatment whether or not insurance coverage exists. Program Rules Acknowledgement I, the parent or legal guardian and the student identified on this form understands that all students are expected to abide by the program rules and are responsible to follow the direction of the COTW staff and/or volunteers. It is further understood that no illegal narcotics, alcohol, cigarettes’, vandalism, weapons (of any kind), rough housing or fighting and any type of disrespect to adult leadership will not be tolerated. I agree with the zero tolerance policy and understand any violation could result in immediate suspension from Program and if necessary student will be returned home will all cost of transportation/air fare being absorbed by me the parent. Any vital information regarding illegal activities will be given to the proper authorities, if necessary. It is also understand by all parties that students are not allowed to leave Program with any individual that is not authorized to pick student up, unless prior arrangements have been made with Youth Pastors. I agree that this rule is not an inconvenience but rather for the safety of student and piece of mind. Media Release I do give COTW permission to use photos, video, and media taken at during this program in promotional materials whether printed or electronic. Liability Release I do release and hereby agree to hold blameless the COTW and all its employees, volunteers and agents from any and every claim arising, or which may be asserted by me or by any member of my family for any reason of students participation, transportation, or medical treatment (including administration of medications) during any Program associated with COTW. My consent and signature is given below. I have read, understand, and agree to the information given in this form. I also agree to resolve any dispute through a mutually acceptable arbitration process. ________________________ ___________ Student’s Name (Print)

________________________ ___________ Student’s Signature

________________________ ___________ Parent/Guardian Name (Print)

________________________ ___________ Parent/Guardian Signature

________________________ ___________ Date


2010 24Seven Holiday Party