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CFC

YOUTH SOCAL MUSIC MINISTRY RETREAT 2012

PARTICIPANT NAME: __________________________________________ EMERGENCY INFORMATION


Name:______________________________Relationship:________________________

Phone #:______________________Cell/Pager #:______________________________ Family Doctor:_________________ Phone/Pager #:___________________________ Hospital Name:______________________Address:___________________________ Medications Currently Taken:____________________________________________ Medications/Items Allergic to:____________________________________________ Physical Activity Restrictions:_____________________________________________

CONSENT & RELEASE WAIVER FORM


I am the undersigned parent and/or guardian of the child whose name appears below, hereinafter known as Participant, and I hereby give my consent for the Participant to attend the CFC-YOUTH Socal Music Ministry Retreat, in Castaic, California on June 15-16, 2012. CFC-YOUTH and its Ministries, organizers and leaders are, therefore, fully absolved and released from any and all responsibility and/or liability that may directly or indirectly arise from or be incidental to the Participants attendance, participation and involvement in any and all activities within the scope of the pre-conference. I understand and agree that I hold CFC-YOUTH, its Ministries, organizers and leaders free and harmless from any liability, costs or damages to any person/s and/or property caused by, arising out of, or incidental to, the Participants attendance, participation and involvement in this pre- conference. By signing below, I certify that all the above information is true and correct to the best of my knowledge, and I fully and voluntarily agree to the above consent and waiver.

__________________________________ ____________________________________
Signature of Participant

Signature of Parent/Guardian

__________________________________ ____________________________________ Date Date