Winter Weekend St. Louis
 
Winter Weekend St. Louis
First Name  * 
Last Name  * 
School Grade Completed  * 
Street Address  * 
City  * 
State  * 
Zip  * 
Daytime Phone  * 
Cell Phone  * 
Name Parent/Guardian  * 
Any severe allergies or medical issues? If yes please explain.  * 
Insurance Carrier and Policy Number  * 
I, the parent or guardian of the previously named student, authorize the participation of my student in this event.
I give permission for my students photo to be taken and used for publicity and recognition of this program.
I consent to medical treatment in the event my student is injured or becomes ill during event activities and authorize the church, staff, or volunteers to make medical decisions.
On behalf of my student as parent/guardian, I hereby release/hold harmless, indemnify, & covenant not to sue the church or youth department, or the volunteers & participants thereof.
Your Email Address  * 
Total $
 
 
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