G.A.M.

E Waiver of Liability, Disclaimer and Permission

PLEASE READ CAREFULLY – SIGNATURE REQUIRED

Required Student Information:

I am registering my student for: _____________________________________________________

Last Name: ______________________ First Name: _________________________ MI:______

Gender: M / F Home Phone:__________________________ Birthday: ________________

Address: ______________________________________________________________________

City: _________________________ State: ______________________ Zip: _______________

Required Parent/Guardian Information:

Father/Guardian Name:____________________ Mother/Guardian Name:____________________

Telephone: Work:______________________ Telephone: Work: _____________________

Cell:_______________________ Cell:_______________________
Home: _____________________ Home: _____________________

Employer: _____________________________ Employer: _______________________________

Other Emergency Contact: ______________________________ Telephone: ___________________

Does this child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of
respiratory illness or any other significant medical condition? YES____ or NO____
If YES, please state condition and explain in detail:____________________________________________

_____________________________________________________________________________________

Do you wish to have your student’s doctor contacted in case of emergency? YES____ or NO____

Doctor’s Full Name: ______________________________ Phone: ___________________________

Emergency Authorization (Signature Required)

I, the undersigned, parent or legal guardian of the participant, a minor, hereby authorize the team/group leaders, or parents of
team/group members acting in the capacity of activity supervisors/vehicle drivers, as my Agents, to consent to medical,
surgical or dental examination and/or treatment. In case of emergency, I hereby authorize treatment, and/or care at any
hospital. If there is an emergency and I cannot be reached, please contact the above emergency contact.

Authorization Signature: ___________________________________ Date:_____________________

Waiver of Liability, Disclaimer and Permission (Signature Required)

I, the parent or guardian of the above named individual, acknowledge that participation in this event or activity involves risk of
physical injury. I further acknowledge that the programs of Galilee Christian Church are primarily administered by employees,
parents and other adults, who volunteer their time, and are not paid professionals. In consideration for accepting the
registration of the named individual and permitting the voluntary participation of said individual in its programs, I hereby
release, discharge, and hold harmless Galilee Christian Church, its employees, volunteers and other representatives from any
claims arising out of or relating to any physical injury that may result to said individual while participating in a Galilee
Christian Church sponsored event, including any physical injury resulting by the negligence of any employee, parent or other
volunteer while performing his/her duties during any event or activity.

Authorization Signature: ___________________________________ Date:_____________________