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

First Name

Last Name

Legal Guardian's Name

First Name

Last Name

Relationship To The Child

Father

Mother

Grandparent

Other (if other list your relationship in the space below)

If other than parent or grandparent list relationship here:

Email Address

Phone

(###)

###

####

Child's Date of Birth

YYYY

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

List Any Allergies We Need To Be Aware Of Below.

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.

By Clicking here I confirm that I am the legal guardian of this child and I am agreeing to the release of Liability.