Hearts on Fire Student Conference

Name

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Phone

Address

Grade

6th 7th 8th 9th 10th 11th 12th Adult Sponsor

Things We Should Know (Allergies, Medications, Etc.)

Emergency Contact (name, cell number)

Disclaimer/FYI

Payments are due by November 1 Completed Medical Release Form. Check this box if you permit us to use digital images (photos) of your kid(s) for social media, advertising, and/or video production for Merge Student Ministry and Broadway Baptist Church.

Medical Release and Permission: I give permission for my child to travel with Broadway Baptist Church to Pigeon Forge, TN, November 21-23. I do hereby verify that the information is correct and grant permission for the church to obtain medical attention in case of sickness or injury to my student. I also grant permission for an attending physician or hospital to perform whatever care deemed necessary by the church for the welfare of my student until you are able to reach me personally. I also release, absolve, indemnify, hold harmless, and forever discharge the church, the organizers, sponsors, and supervisors from any and all claims, demands, actions, or cause of actions, past, present, or future arising out of injury or damage while participating on this trip. I assure all risks and hazards incidental to the conduct of the activities and transportation to and from the area. In case of the injury to my student, I hereby waive all claims against the organizers, the sponsors, or any supervisors appointed by them. I likewise release from responsibility any person transporting my student to and from the activities. I agree to provide medical insurance for my student.

Yes

Parents: If you would like to volunteer in some capacity, let us know. We will be in touch.

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Payment

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Hearts on Fire Student Conference

Description

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