Parent/Guardian (1) Information
Please fill out primary parent/guardian information here.
Parent/Guardian (2) Information
Please fill out secondary parent/guardian, or other emergency contact information here.
Please fill out child information here.
Parental Authorization, Consent & Release
____________________________, parent/guardian of _________________________, hereby grant my permission for my above-named child to ride in vehicles provided by Wellspring Church and to participate in activities prescribed by Wellspring Church and/or CIY SuperStart! I understand it is my obligation to inform the Church of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities while in the care of the Church. Should the need for medical attention arise I understand the Church will attempt to contact me as soon as practicable under the circumstances. In cases of emergency, I further consent to the examination and treatment of my above-named child by medical personnel as deemed necessary by such personnel. I agree to pay for any and all resulting medical expenses. I agree to waive, forever discharge, covenant not to sue and agree to hold harmless all Event sponsors and the Church, their agents, representatives, employees, sponsors, successors and assigns (“the Released Parties”), from all liability, claims, demands, losses or damages on account of or caused by, whether actual or alleged, in whole or in part, any act or omission of the Released Parties in connection with my child’s participation in the Event. I acknowledge by signing this form I am waiving my right to maintain a lawsuit against the Released Parties on the basis of any claim from which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions remain in full force and effect. I have fully informed myself as to the contents of this PARENTAL AUTHORIZATION, CONSENT AND RELEASE by reading it before I signed it.
By typing your full name and date, you are electronically signing this form and acknowledging that your online consent is equivalent to a binding legal signature.
Payment of $75 will go towards your child's attendance at the event, hotel accommodations, and two meals.
(scholarships may be available, must contact church prior to submitting this form)
Your child will also be responsible for the cost of 1 meal, snacks, and any incidentals (one fast food meal on the way to the event, and any snacks or optional merchandise purchased on the way to/from and during the event).
We recommend $10-20 dollars. Please have your child's money in a ziploc bag, labeled with their first and last name.