ELEVATE SUMMER REFUEL

Student Name *

First Name

Last Name

Student Date of Birth *

MM

DD

YYYY

Student Mobile Phone Number *

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Parent Name *

First Name

Last Name

Parent Mobile Phone Number *

(###)

###

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Parents Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY *

* ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY I hereby consent to my child participating in the programs of the Life Church Elevate Refuel.  I understand that injuries can occur and risk is involved in any activity for my child.  I further agree that Life Church, along with the employees, agents, officers, and directors of Life Church shall not be liable for any losses or damages occurring as a result of my child’s participation in activities, except where such loss or damage is the result of the intentional or reckless conduct of one of the organizations or individuals  identified above.  This acknowledgment of RISK AND WAIVER OF LIABILITY has been read and is signed voluntarily.

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