Parent/Guardian’s First & Last Name *

First Name

Last Name

Phone *

(###)

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Parent/Guardian’s First & Last Name

First Name

Last Name

Phone

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Phone *

(###)

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Child #1 *

First Name

Last Name

Date *

MM

DD

YYYY

Child #2

First Name

Last Name

Date

MM

DD

YYYY

Child #3

First Name

Last Name

Date

MM

DD

YYYY

I agree on behalf of myself, my child named herein to participate in this ministry of Cornerstone Community Church, its leaders, volunteers/ chaperones, its employees, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness, injury, or medical treatment in connection therewith. And I agree for my child to receive medical attention (if required) while with the church, its leaders, its employees, chaperons, or representatives associated with the event provided by Medicare. And if any costs are not covered by Medicare, I am responsible for the fees and expenses which may incur in any action brought against my child as a result of such injury or damage. Emergency Medical Treatment: In the event of an emergency, I hereby give permission for Cornerstone Community Church and its representatives to transport my child to a hospital if emergency medical or surgical treatment is necessary. CCC will notify the signed below or the emergency contact if such is the case. *

I give permission for my child's photograph to be taken and used by Cornerstone Community Church on their website and/or social media platforms.

Yes

No

Date *

MM

DD

YYYY