MVMT HS Houseboats 2024

Student's Name

Address

Student Email

Student Phone Number

Shirt Size

Grade

Parent/Guardian

Parent/Guardian Cell Phone

Parent/Guardian Email

This address will receive a confirmation email

Emergency Contact (other than parent)

Emergency Contact Phone

Permission & Medical Release

My student has permission to participate fully in Houseboats from June 21-June 24 2024

Yes No

Does your student have any food allergies?

Yes No

If food allergy, please list.

Does your student have any dietary restrictions?

Yes No

If dietary restrictions, please list.

Does your child have any allergies or medical conditions we should be aware of? Does your child take any medications?

Yes No

If yes, please explain:

Physician's Name

Physician's Phone

Insurance

Group Number

In case of emergency, I can be reached by phone number listed on this form. In the event I cannot be reached, I give my permission to the licensed physician, nurse or medical care provider designated by the group leader to secure medical aid as required for illness or injury under a physician's orders, including transportation to and from the necessary facilities. I accept the cost of any such treatment. I hereby release and hold harmless Community Bible Church and camp staff from any and all liability for accident or injury that might occur while participating in and/or traveling to and from such events.

Date:

Parent/Guardian Legal Signature

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

MVMT HS Houseboats 2024

Description

Please Fix the Following