Student's Name*Date of Birth* MM slash DD slash YYYY Grade*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact #1 Name*Emergency Contact #1 Phone*Emergency Contact #1 Email* Emergency Contact #2 Name*Emergency Contact #2 Phone*Emergency Contact #2 Email* Health/Medical Insurance Co.*Policy Number*Medical Conditions*Does the student have any medical conditions, food allergies or special needs that we should be aware of?noyesMedical Conditions Explanation*Please explainWhich event(s) are you giving consent for?*Consent Agreement*As a parent/legal guardian. I have reviewed the information and give permission for the subject of this release to be involved in the overall activities of this event. I/We understand all reasonable safety precautions will be taken at all times by City Church for All Nations Youth Team. and its agents during the events and activities. I/We authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold City Church for All Nations, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. I ConsentToday's Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.