Game Waiver Form

G.A.M.E Waiver of Liability, Disclaimer and Permission PLEASE READ CAREFULLY – SIGNATURE REQUIRED Required Child Information: I am registering my student for: _____________________________________________________ Last Name: ______________________ First Name: _________________________ MI:______ Gender: M / F

Home Phone:__________________________ Birthday: ________________

Address: ______________________________________________________________________ City: _________________________ State: ______________________ Zip: _______________ Required Parent/Guardian Information: Father/Guardian Name:____________________ Telephone:

Mother/Guardian Name:____________________

Work:______________________ Telephone: Cell:_______________________ Home: _____________________

Employer: _____________________________

Work: _____________________ Cell:_______________________ Home: ______________________

Employer: _______________________________

Other Emergency Contact: ______________________________ Telephone: ___________________ Does this child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition? YES____ or NO____ If YES, please state condition and explain in detail:____________________________________________

Do you wish to have your student’s doctor contacted in case of emergency? YES____ or NO____ Doctor’s Full Name: ______________________________ Phone: ___________________________ Emergency Authorization (Signature Required) I, the undersigned, parent or legal guardian of the participant, a minor, hereby authorize the team/group leaders, or parents of team/group members acting in the capacity of activity supervisors/vehicle drivers, as my Agents, to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby authorize treatment, and/or care at any hospital. If there is an emergency and I cannot be reached, please contact the above emergency contact. Authorization Signature: ___________________________________ Date:_____________________ Waiver of Liability, Disclaimer and Permission (Signature Required) I, the parent or guardian of the above named individual, acknowledge that participation in this event or activity involves risk of physical injury. I further acknowledge that the programs of Galilee Christian Church are primarily administered by employees, parents and other adults, who volunteer their time, and are not paid professionals. In consideration for accepting the registration of the named individual and permitting the voluntary participation of said individual in its programs, I hereby release, discharge, and hold harmless Galilee Christian Church, its employees, volunteers and other representatives from any claims arising out of or relating to any physical injury that may result to said individual while participating in a Galilee Christian Church sponsored event, including any physical injury resulting by the negligence of any employee, parent or other volunteer while performing his/her duties during any event or activity. Authorization Signature: ___________________________________ Date:_____________________ Insurance Information Partipant Name: ___________________________________________________ Insurance Co.: ___________________________________________________ Policy NO: ____________________________________________________ Group NO: ____________________________________________________ Phone NO: ____________________________________________________