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Non-Profit Org.

US Postage
3031 Long Hollow Pike PAID
Permit No. 17
Hendersonville, TN 37075
Goodlettsville,
615.824.4006
TN 37072

Long Hollow Baptist Church Medical Release Form


Name_______________________________________________________ Birthdate_______________________ Grade______________
Address ______________________________________________________________________ School___________________________
City/State/ZIP________________________________________________________ Home Phone________________________________
Student’s cell phone _______________________________ Student’s Social Security #________________________________________
Student’s e-mail _________________________________________________________________________________________________
Parents’ Names______________________________________________ Parents’ Work Phone__________________________________
Mother’s cell _________________________________________ Father’s cell _______________________________________________
MEDICAL INFORMATION
Family Physician______________________________________________________________ Phone_____________________________
Address___________________________________________________________ Emergency Phone_____________________________
Insurance Company___________________________________________________ Policy #____________________________________
Member’s Name______________________________________ Ins. Company Phone #_______________________________________
Allergies_______________________________________________________________________________________________________
Medication being taken___________________________________________________________________________________________
Physical Handicaps or Special Conditions____________________________________________________________________________
MEDICAL AND SURGICAL WAIVER
Also: Property Damage, Transportation for Disciplinary Reasons and Personal Property Searches
I am the parent and/or legal guardian of _________________________________ and hereby acknowledge that he/she is under my care, custody, and control.
In the event there arises an emergency necessitating medical/surgical attention, I expressly grant my permission and consent to the Long Hollow Baptist
Church staff, its representatives, sponsors, or any attending physician, to make such decisions and to perform such medical treatments and/or surgery upon my
child listed above which may in their sole discretion be necessary and proper under the circumstance. I, the undersigned parent and legal guardian of above
mentioned child, do release, acquit, discharge, and covenant to indemnify and hold harmless Long Hollow Baptist Church or its representatives, the sponsors,
or any attending physician, from any and all actions, causes of actions, related risks and dangers, including negligence, damages, liabilities arising out of the
treatment of any sickness or accident, and any financial responsibility for all medical treatment provided.
I also assume financial responsibility for any damage my child may cause, and for providing transportation home should it become necessary for disciplinary
reasons.
I also give my permission to the Long Hollow Baptist Church staff, its representatives, and the adult sponsors and chaperones to search my child’s personal
belongings, including but not limited to all luggage, purses, and backpacks, if deemed necessary on rare occasion for security reasons.
________________________________________________ _____________________
Signature of Parent or Guardian Date
the theme
A Jewish theologian once said, “He who is not willing to be an
heir, does not deserve to be a pioneer.” In other words, one
how much?
$50
*cost includes program fee, lunch and dinner on Saturday, t-shirt
must become Timothy before one can ever be Paul. This year we and curriculum. Make sure to register your friends early too!
follow the calling of the most dynamic and influential individual,
with the exception of Jesus, in all of history: the Apostle Paul.
From his ultimate calling of salvation to the defining moment of
surrender to capturing the moments of life as a living sacrifice
and finally embodying the concept of service with his dying
how to register:
1. Fill out the registration and medical release form on the
bottom. Turn it in to the welcome desk at Small Groups or in
breath... Paul answered the call. With undeniable clarity, the the Drop Box in the Dome.
calling still exists today to be separated to the gospel of God, 2. Turn your money in to the Drop Box in the Dome, the offering
surrender my life as a blank check to Him, live every moment as slot by the Worship Center, or in the offering basket. Make
if it were my last and serve until my dying breath. sure to put each student’s name in the memo line.

who can attend?


6th - 12th grade students and all their friends
* You can also log on to www.longhollow.com to register and
pay for Quest!

notes:
where?
Long Hollow Baptist Church and local host homes.
A few weeks before Quest, pick up a Preview Pack with all the
details you will need to know for the weekend. This will also
be available online at www.longhollow.com.

Student’s Name: ______________________________________ School: __________________________ Grade: _________


Address: ________________________________________________ City: ______________ State: ______ Zip: _________
Phone: _____________________________ Cell Phone: ____________________________ Campus: Hendersonville
T-shirt size: YM YL YXL S M L XL XXL XXXL Gallatin
List 3 friends
you would like to have in your small group: White House
_________________________________________________ Parent Info:
_________________________________________________ For more information about Quest 2010, pick up a Preview
_________________________________________________ Pack at any of the Welcome Desks. The Preview Pack will
If you were invited by a Long Hollow Student, please list also be availble on www.longhollow.com.
their name here: ___________________________________
Signed: __________________________________________________ (Parent or Guardian) Date: _____________________
Medical Release form on back