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This Changes Everything Elevation 2018

Two step registration:
1. Complete the form below.
2. Pay HERE. Under Payment Purpose choose option "Elevation."

*Full Name of Participant:
*Gender:
*Grade:
*Birthdate:
*Student Email:
*Parent/Guardian Name:
*Parent's Email:
*Parent/Guardian Phone:
Participation Acknowledgement:
Mount Ararat Baptist Church strives to provide safe environments for adults and children in its programs. However, not all circumstances can be anticipated and some risks cannot be eliminated. A permission slip must be submitted for any individual participating in a church activity, trip, or event that takes place away from the church.
Elevation
Feb 15-18, 2018
Risk Acknowledgment:
I hereby certify that I am in good physical and mental health at this time, and wish to participate in the above event/activity. I understand that my participation may result in an unexpected illness or injury, due to accidents, forces of nature, or other unforeseeable events. Such illnesses or injuries could include diseases, strains, sprains, fractures, dislocations, and/or death. These injuries (if incurred) could cause permanent disabilities. I realize that there are certain risks, including death, arising from this activity, and I am willing to assume such risks.
Video/Photo Release:
I also understand that I and/or my child(ren) may be video-taped or photographed for promotional purposes. By signing this release form, I authorize the church to use my and my family’s picture(s) (including photographic and video images) and my and my family’s voice(s) (including sound and video recordings) in any and all media and the Internet. I also waive the right to receive any payment.
Emergency Contact:
In the case of an emergency while the named individual is in the care of Mount Ararat Baptist Church, the church will notify the emergency persons listed immediately. In the event the church is unable to reach these persons, the church party responsible and or its designated staff is authorized to seek and obtain medical attention, treatment, and services as may be deemed necessary until the guardian arrives. The guardian agrees to pay all medical costs incurred.
Please Notify below in case of emergency
*Name:
*Cell Phone Number:
*Relationship to Participant:
Name(2):
Cell Phone number(2):
Relationship to Participant(2):
 Please enter your health insurance information below.
*Company Name:
*Policy#/Group#:
*Policyholder's Name:
*Family Physician's Name:
*Physician's Phone #:
*Allergies (List all allergies to medicine, foods, or other things. If none please put None):
Other Restrictions (please list all restricted activities):
What doctor-prescribed medicine does this person take?:
I give permission to the designated leader to administer all of the following:
Other Med(s):
T-Shirt size:
*Signature: