2008-2009
permission/registration form
event: gender:
student’s name birthdate:
address grade:
city state zip
home phone cell Phone
roommate preference (if any):
mother’s name
phone (h) (c)
father’s name
phone (h) (c)
emergency contact (other than parent) phone
______________________________________ has my permission to attend
student's name
the following activity
name of activity
sponsored by The Sanctuary Assembly of God, Voorhees on .
dates
I am the parent or legal guardian of the student named above, a minor, and has given our consent for him/her to attend events being organized by the Church, including the event specified above. I understand that there are inherent risks involved in any ministry or athletic event. I voluntarily elect or accept and solely assume all risk of damages and injury incurred or suffered by the student named above while attending events organized by the Church, including the event specified above. I hereby agree not to sue and release the Church, its pastors, employees, agents, volunteer workers, elders, and representatives from any and all liability, claims, damages, and costs for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement in events organized by the Church, including the event specified above. I further agree that I shall hold harmless and fully indemnify the parties hereby released from any claims, damages, and costs including attorney fees which may arise from any claim or cause of action made by me, through me or on my behalf even if caused in whole or in part by any of the parties or entities hereby released.
In the event that he/she is injured and requires medical attention, I consent to any reasonable medical treatment as deemed necessary by a licensed health professional. In the event treatment is required from a licensed health professional and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such medical care. I also agree to hold harmless and release the Church, its pastors, employees, agents, volunteer workers, elders, and representatives from any and all liability related to expenses arising from the giving of such medical care to the extent those expenses are not reimbursed by my or the student’s health insurances. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above at the time of the event specified above. I also agree to bring my child home at my expense should he or she become ill or if a student ministries staff member deems it necessary.
I understand that this form does not guarantee my student a spot on the aforementioned trip, rather it enters them in the registration process. I also agree to forgo any money paid for a given event as refunds are only given in case of emergency cancellation (i.e. death in the family, illness).
I ACKNOWLEDGE THAT I HAVE READ
Parent/guardian signature:
Date
student’s information
insurance co. policy #
group #: _______________________________ insurance co. phone #:
physician office phone
please list any known allergies:
please list any medications taken on a regular basis and what they’re treating:
for
for
for
all information in this box needs to be completed
for assistance info.
FOR OFFICE USE ONLY
Date Received:
Check #:
Amount:
Assistance amount applied:
Contact Person (s): Relationship:
Need-Based Assistance
Need-Based Assistance is provided to students in difficult financial situations. It is a means for students to be
able to participate in a given Journeyouth activity without the burden of financial unavailability. It is a blessing for The Sanctuary to be able to provide this assistance for trips and events and it is our desire to continue this option in the future. In order for that to be a possibility, we ask that you consider the following information.
Assistance is offered in 3 different levels:
1. 50% of total cost
2. Partial payment (i.e. $50)
3. Full assistance for extreme need
If you are interested in applying for Need-Based Assistance for your student, please note the following guidelines:
1. Parents are responsible for calling the Sanctuary office to request and discuss their needs and options.
Requests will not be processed from students.
2. Upon calling the church office, parents will discuss with their student which avenue they would choose to contribute to their assistance:
A. At a rate of $10/hour students can work in their own homes or neighborhoods providing free chores to those in need. [i.e. babysitting, leaf raking, shoveling, baking, etc]
B. Also at a rate of $10/hour students can work here at The Sanctuary by coordinating with Beth Jackson
[Church Secretary] a schedule that is helpful for both the facilities staff and the student.
3. Students will be responsible for working off the majority (preferably all) of the hours before the trip or event.
If hours are not completed ahead of time it is expected that the student will follow through after the trip or event.
4. Multiple students involved in The Sanctuary does not automatically qualify/justify assistance.
5. Please note that assistance is not given to students whose parents desire their student to work for a camp /conference registration fee in order to learn the value of a dollar. Rather, they are available to students who would not be able to consider attending purely for financial reasons.