Paintball Release Form for Hope Lutheran Church

Youth Name

Youth Birthdate

Youth Cell Phone (if applicable)

Are you are friend of one of the Hope Lutheran Youth? If so please name here.

Grade entering in Fall of 2020

6th 7th 8th 9th 10th 11th 12th

Address

Parent/Guardian #1 Name

Parent Cell Phone

Other Phone (if applicable)

This address will receive a confirmation email

Emergency Contact (should above parent not be reached)

Relationship to Youth:

Emergency Contact Cell Phone

Emergency Contact Alternate Phone (if applicable)

Medical Insurance Company

Policy Holder's Name

Policy/Certificate Number

Does the participant have any allergies? Yes No

If yes, please list and/or explain type of allergies and reaction:

Please list any medications being taken, medical problems, or other pertinent information including physical, mental, or psychological conditions that may require medication, treament or restrictions:

NOTE: This is an off site event

Additional release forms from our 3rd party locations including Vintage Paintball is required.

Closed toe shoes and long pants are REQUIRED. Please also bring a water bottle and change of clothes for after the event (suggested). Sunscreen & bug spray may also be good to have.

I understand and will have closed toe shoes and long pants

The undersigned hereby gives permission for my child to ride in a vehicle driven by an approved and licensed ADULT chaperone (25 years of age or older) while attending and participating in activities sponsored by Hope Lutheran Church. I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

I agree I DO NOT agree

Photo Image Release: As a participant in a Hope Lutheran Church event, I give permission and consent to allow photos, and videos, to be taken of the above mentioned individual during the event. I further give consent that any such images or videos may be published in a variety of ways and used to illustrate and promote Hope Lutheran Church.

I agree I DO NOT agree

Authorization for Treatment: I hereby authorize the Hope Lutheran Church staff and volunteers to administer medications and first aid as deemed necessary as well as authorize the medical personnel selected by Hope Lutheran Church Staff to provide emergency medical care by medical staff to hospitalize, secure treatment for, order injection, anesthesia, blood transfusions, or surgery, and to release any records necessary for insurance purposes as well as provide or arrange necessary related transportation for the above named participant. This form may be photocopied.

I agree I DO NOT agree

Event Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Paintball Release Form for Hope Lutheran Church

Description

Please Fix the Following