Please provide the name of the event your student will be attending.
Please select
In the case of an emergency and neither parent can be reached who would you like to be contacted. Please provide name and phone number.
Please provide: Insurance Company Name, Phone Number, Policy Number, Group Number
Dr. Name and Phone Number
Medical, Special Need etc.
I do hereby, release, indemnify and hold harmless Reliance Church its staff, officers, and volunteers from any liability in case of, but not limited to, accident, illness, or injury while being transported to and from and attending the above named event. -give my permission to Reliance, its staff, officers, and volunteers to select transportation to their chosen physicians who may hospitalize, secure proper treatment for, order injections, anesthesia, or surgery in emergency situations for my above named child. -understand that if the above name child participates in any defiant conduct, I may be contacted and obligated to remove my child from the care of Reliance Church.
I give permission that any photos or video taken of my child or anything they write may be used for future printing and publication for promotional purposes, including but not limited to website photos and brochures used for advertising purposes . Reliance Church reserves the right to use any photograph/videography or other, similar reproductions or recordings taken on Reliance Church property or at any event sponsored by Reliance Church. Reliance Church also reserves the right to use any photograph/videography without the written permission of those included within the photograph. Photographs may be used in publications or other forms of media produced, used, or contracted by Reliance Church. This includes, but is not limited to: magazines, Web sites, social media, blog, presentations and other Reliance Church marketing materials or other, similar reproductions or recordings.
