SUSPENDED FORM

Students Name

Church Attending with

Last Grade Completed

Gender

Date of Birth

T-Shirt Size

List any medical conditions, medications, allergies or any other info that will help us provide a safe environment for your student

Guardians Name

Relationship to Student

Address

Phone

Emergency Contact

Emergency Contact Phone

Waiver of Liability and Medical Release

I have read and agree to the terms laid out in the above Medical Power of Attorney and Release.

Name

Date

Electronic signature

Clear