GAP MOVIE LOCK IN

JULY 12TH AT 7PM

Pizza & Breakfast will be provided but you will need to bring drinks, snacks, etc. Sign up using the form to the right if you want to attended.

Child's Name *
Child's Name
Legal Guardian's Name *
Legal Guardian's Name
Relationship To The Child *
Phone *
Phone
Child's Date of Birth *
Child's Date of Birth
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
RELEASE OF LIABILITY *
I, the undersigned, parent/guardian of the above named person, a minor, do hereby authorize Life Church as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medical practice Act on the medical staff of any accredited hospital, where such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. I further agree to be responsible for all costs associated with any treatment provided in compliance or attempted compliance in good faith with this consent.