Winter Fest 2018


* Indicates required field.


I hereby give my full consent to Lawrenceville Church of God to record my participation in any programs or events associated with Fuze. Further, I hereby transfer and assign to LCOG the exclusive right to use and to authorize others to use said images, video, and audio recordings for promotional and educational use or resource sale in the future. I understand that my image may be used, but my name or personal information will never be shared publicly without additional,separate consent.

Student Signature*:
Parent's Signature*:


The following youth activities, operated by Lawrenceville Church of God, under the supervision of the staff and volunteers of Lawrenceville Church of God, require the completion and acceptance of a medical release prior to participation.

Student Name*:

I, for the student indicated above, apply to Lawrenceville Church of God to participate in the activity described and indicated above ("Activity"). I acknowledge and agree to, and represent, the following for myself and the student, in consideration of the opportunity to be provided by the Church (contingent upon its agreement to my child's and/or my participation).

Acknowledgement of Risks. I acknowledge that participating in the Activity involves risks of serious damage and harm to persons and property, and even death, arid I assume those risks, including risks arising from acts or failures to act of the Church.

Information Relied on by Church. I am the parent or legal guardian for the student for whom this document is signed. The student is in good health and sound mind. If necessary, I have discussed or will discuss with my physician the student's participation in the Activity, and the student has received or will receive any vaccination or other recommend prerequisite medical treatment my physician deems necessary. The student will participate in the Activity only if I have received my physician's approval, if I deem it necessary, and believe that the student is able to participate without harm. I acknowledge that the Church will not assess or approve the student's fitness for participation. I am under no force or . duress of any kind to compel the student's participation in the Activity or my signing ofthis document.

Release. THIS DOCUMENT IS INTENDED TO ABSOLVE THE CHURCH OF ANY LIABILITY TO ME OR THE STUDENT THAT IS RELATED TO THE STUDENT'S PARTICIPATION IN THE ACTIVITY. Accordingly, l hereby release the Church from, waive, and will never sue the Church for, any damage (whether damage to or loss of property, finances, life, body, mind or emotions), cost suit, demand, claim, or other liability, that arises or is alleged to arise from or in connection with the student's participation in the Activity. Such liability includes any liability that arises or is alleged to arise from the Church's negligence (but not willful and wanton misconduct). Such liability also includes any liability that arises or is alleged to arise from claimsfor contribution by another that the student or I have sued or from whoin the student or I have received compensation.

Medical Permission. I give my permission for the student to be treated for illness or injury sustained while participating in the Activity, including by the administration of emergency anesthesia or surgery; and authorize the adult leaders of the Activity to act on my behalf in ordering such treatment.

Definitions. (a) References to "me," "my," and 'T' shall include and bind the student, my spouse; any parent of the student for whom this document issigned, any guardian or other person with responsibility for the care and supervision of such student, and any insurer, heir, estate, legal representative, executor, adminstrator, successor, or assign of me or such student. (b) " Participation" or " participating" in the activity Includes planning arid preparing for, traveling to, and traveling from, as well as participating in, the Activity. (c). The "Church" includes (i) its affiliates and institutions cooperating in the Activity; (ii) the trustees, elders, deacons, officers, employees, volunteers, and agents of the Church or such affiliate or instituition; and (iii) the spouses, insures, heirs, estates, legal representatives, executors, ,adminstrators, successors, estates, and assigns of any of the foregoing.

Parent/Guardian Signature*:


In the event of an emergency, the most accurate and updated information will be extremely helpful for us in providing the best care for your student.

List all Medical Conditions and any current Medication regimens:

List all known Allergies:

Alternate Emergency Contact (other than Signer of this Release)

Relationship to Student*:


Student Full Name:
Student's Date of Birth:
Parent Names:
Parent Cell Phone 1:
Parent Cell Phone 2:
Home Phone:
Alternate Phone:
Home Address:
Zip Code:
Insurance Carrier:
Policy #/ Group #:
Policy Holder's Name:
Date of Birth:

Prescription Coverage (if applicable)

Insurance Carrier:
Policy #/ Group #:
Policy Holder's Name:
Date of Birth:

Parent's Signature*: