Medical Wavier

Permission Wavier Form Online

* Indicates required field

Name of Event *

Date/Dates of Event *

Address of Event *

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Parent or Guardian *

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Phone Number *

Participant 1 *

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Birth Month *

Birth Day *

Birth Year *

Participant 2 *

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Birth Month *

Birth Day *

Birth Year *

Participant 3 *

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Birth Month *

Birth Day *

Birth Year *

Participant 4 *

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Address *

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Emergency Contact *

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Email *

Phone Number *

Address *

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Family Insurance Company *

Insurance ID # *

Subscriber Number *

Policy Holder's Name *

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Insurance Company's Phone Number *

Primary Care Physician *

Doctor's Office Phone Number *

Allergies of Each Participant *

Diet/Activity Restrictions *

Does each Participant have the ability to Swim ? *

Permission/ Waiver Online Form:
I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the Participation of my child in all the regularly-scheduled activities at Restoration Church, located in Green Bay, Wisconsin, including field trips, camp outs, swimming, boating, hiking, sporting events, and any other activities customarily associated with a church activity. The undersigned agrees and does hereby release from liability and hold harmless Restoration Church and any of its employees or agents for any and all liability for personal injuries including death and property losses and damages in connection with any activity or accommodation of Restoration Church. The church DOES NOT provide accident/injury insurance. Financial obligations for medical expenses and/or mental emotional trauma are a parent/child responsibility. In addition, I authorize Restoration Church. to take and use any photo or video for the specific use of publicity within the realms of tv, internet, or printed material. It is the parent’s responsibility to notify the church leadership responsible for the activity of any change in information. The undersigned does hereby further agree to abide by all the rules, regulations, and directions presented by Restoration Church and its agents or employees.

Do you agree to the terms & conditions? *

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