AGAPE CHRISTIAN FELLOWSHIP

Where serving God is our passion

Generation Impact (G.I) Youth Ministry Activity Consent Form
Students Name: __________________________________________ Date of Birth _____/______/______

Parent/ guardian: ____________________________________________________________________________ Address __________________________________ City_______________________ State_____ Zip___________ Phone (Home) _________________________ (C) ______________________________ (W) ________________ (Alt) __________________________ Students Cell Phone Number _____________________________________ Email address _________________________________________________________________________________ Does Your Child have Medical Insurance: YES NO (please circle one)

Medical/ Dental Provider ________________________ ____________________________ Date & Time: Logistics: Wednesday, March 19, 2014, 2013 5 P.M. 9:30 P.M.

Transportation via church van, departing from ACF parking lot at 5pm.

I hereby give permission for _____________________________________ to attend Lehigh Spring Festival, Veterans Park, 55 Homestead Road, Lehigh, FL with G.I Youth Ministry. Fees: $ N/A Medical restrictions Special considerations or restrictions: ____________________________

My Child has allergies to the following foods, insect bites or stings________________________________ Hold Harmless Agreement I understand that participation in certain G.I activities can involve a certain degree of risk and can be physically, mentally, and emotionally demanding. I have carefully considered the risk involved in this current activity and have given consent for myself or my child to participate in this activity. I also understand that participation in this activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release the Agape Christian Fellowship, G.I Youth Ministry, Youth Leaders, and all ACF employees, volunteers and chaperones associated with the activity from any and all claims or liability arising out of this participation. In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the emergency medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participants parent or guardian, and/or determination of the participants ability to continue in the field trip activities. Participants Signature: ________________________________ Date __________________________ Parent / Guardian Printed Name: ________________________________________________________ Parent / Guardian Signature: ___________________________ Date___________________________