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Fuddruckers and Frankie’s Fun Night Signup
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Fuddruckers and Frankie’s Fun Night Signup
1
Fuddruckers & Frankie's Fun Night
Child's First Name
Last Name
Do you have more than 1 rising 7th grader?
Yes
No
2nd Child's First Name
Last Name
Email
Emergency Contact Person
Emergency Contact #
provide best number to contact
Parent/Guardian Name
Insurance Company Name
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Policy #
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Can your child be given ibuprofen, tylenol or benadryl?
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Allergies, medication(s), or medical conditions we need to be aware of.
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Any additional information we need to know
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I hereby give permission for our/my child(ren), to attend, participate in activities, and be transported by approved volunteers sponsored by: Hope Point Church on the evening of Thursday, August 3, 2017.
We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any examination, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist.
I understand that I shall be liable and agrees to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) pursuant to his authorization.
I understand that if I do not have medical insurance, I, as the parent or guardian, or I as an individual eighteen years of age or older, will be responsible for any medical expenses in the event of a sickness and/or injury.
I also hereby give permission for our (my) children to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Hope Point, hereby releasing the church, its pastors, employees, and volunteers from liability.
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Hope Point Church - Spartanburg, SC
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