NazStudents Activity Waiver and Photo Release 2023-2024
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The undersigned does hereby give permission for the below mentioned student to attend and participate in the activities of my (our) choice that are associated with the Youth and Children’s Ministries at Mustang Nazarene Church during the school year of 2023-2024. We, the parent(s)/guardian(s), do hereby release and will hold Mustang Church of the Nazarene, and any connected affiliate, harmless of any and all liability and claims resulting from any injury, loss, or accident that might occur to said minor(s) while participating in the activities affiliated with the church during the designated year. This release shall also constitute authority to the Leadership of Mustang Church of the Nazarene to consent for any doctor, nurse and/or hospital to administer medical aid and treatment for the minor if an accident is sustained or emergency exists. This includes any X-ray examination, anesthetic, surgical or dental diagnosis or treatment and hospital care.
Please select one option.
Parent/Guardian Name
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Parent/Guardian Email
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This address will receive a confirmation email
Parent/Guardian Phone
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Address
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
STUDENT Name
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STUDENT Birthdate
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STUDENT Phone (if applicable)
Grade Beginning Fall of 2023
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Please select all that apply.
7th
8th
9th
10th
11th
12th
Emergency Contact
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Emergency Contact Phone Number
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Does the Student have any allergies or need any special accommodations?
*
Insurance Information (for Youth OverNight Trips)
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Insurance Name
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Group Number
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Insurance Contact Number
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Please upload a copy of insurance card
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Upload (8MB)
I give consent for pictures or videos of my student to be posted on social media or church publications.
*
Please select one option.
Yes
No
Parent/Guardian Responsible Party Digital Signature
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Today's Date
*
Submit
Description
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