New Years Lock-in Parental Release Form

FRESH START New Year’s Lock-in Event Authorization and Release Form We (I), the undersigned parent(s) of __________________________ hereby authorize and approve the said student’s travel for the event FRESH START New Year’s Lock-in that he or she participates in. The undersigned hereby releases FRESH START, it agents, employees, members, sponsors, ministers and vehicle drivers from liability, claims, demands, actions and causes of action whatsoever arising out of, or related to, any loss, damage or injury which may be sustained by the above referenced said student or the undersigned parent or guardian while the said student is traveling to or from, or participating in, any FRESH START, church activities or trips. In the event of an accident or injury to the above named student, when time is of the essence, I hereby authorize the event sponsor(s) to seek and authorize medical treatment by the best available medical personnel. Please complete to following information then sign and date this form. Parent(s) or Guardians full name: ______________________________ Phone number:__________ Cell number: _________ Work Number: _________ IF you are not available contact: ____________ phone number: __________ Insurance company: ____________________ Policy Number: _______________ Insurance company Phone number: __________ Family Doctor: ____________________ Phone number: __________ Please list any allergic reactions or medications your child has: _____________________________________________________________________ _____________________________________________________________________ Executed _____________________ (Date) ____________________ ____________________ ____________________ Student Parent or Guardian Parent or Guardian

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