Child Name *
Child Name
Month/Day/Year
Child #2
Child #2
Child #3
Child #3
Parent / Guardian *
Parent / Guardian
Address *
Address
Please list 2 phone numbers with the name, number and relationship to child(ren).
Do you have insurance *
If you have medical insurance your carrier will be billed for medical charges in the event of illness or injury while your child is at Wilkinson Church of Christ Activities, Events, and on Trip.
Please list information for each child here. Form does not allow you to "enter". Type continuously listing each child's name and condition.
--I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event that I cannot be reached in an emergency during any activities sponsored by Wilkinson Church of Christ, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. --I understand that my insurance coverage for my child will be used as the primary coverage in the event medical intervention is needed. Coverage by Wilkinson Church of Christ through its accident policy will be used as a backup for what my insurance does not cover. --I understand all reasonable safety precautions will be taken at all times by Wilkinson Church of Christ and its agent during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Wilkinson Church of Christ, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form --I consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the subject of this release during all activities to be used, distributed, or shown as Wilkinson Church of Christ sees fit. --I give permission of Wilkinson Church of Christ, its staff and volunteers to take my child on trips/event/retreats that require them to leave the campus of Wilkinson Church of Christ during regularly scheduled meeting times. I understand that whenever possible, I will be notified prior to the event. Please type AGREE and hit the SUBMIT button.