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Nazarene Medical & Civil Liability Release form - SP26
IT IS YOUR RESPONSIBILITY TO READ AND UNDERSTAND THIS FORM BEFORE SIGNING
Clergy Kids Retreat
Event Dates:
February 14, 2026 - February 16, 2026
Due Date:
Upon Registration
Participant First Name
Participant Middle Name
Participant Last Name
Country
Street
City
Region
Postal Code
Student Email
Gender
Gender
Female
Male
Birthdate
Birthdate
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IF YOU ARE UNDER 18 YEARS OF AGE, A PARENT OR LEGAL GUARDIAN MUST READ & SIGN THIS FORM
Parent Information
Delete
Emergency Contact
_ID_
Parent/Guardian First
Parent/Guardian Last
Relationship
Father
Mother
Legal Guardian
Parent/Guardian
Mobile Phone
Work Phone
Add $nth Emergency Contact
Doctor's Name
Doctor's Phone
Health Insurance Company
Policy #
Customer Service Phone # for emergencies
NAME(S) & DOSAGE(S) OF MEDICATIONS YOU WILL BE TAKING:
ALLERGIES, MEDICAL CONDITIONS, ACTIVITY LIMITATIONS:
DATE OF LAST TETANUS SHOT:
“I, authorize Event leadership to care for the administration of general first aid treatment for any minor injuries received to my child during the event. If the injury sustained is life-threatening, or in need of emergency treatment, I authorize the leadership of or its representative to summon any and all professional emergency personnel to attend, transport, treat my child.
I understand that event staff will require my son/daughter to make choices and keep a schedule, and that he/she may not be under direct adult supervision at all times. Unless there is negligence on the part of any staff or lay assistants of Nazarene Youth International Ministries, the General Church of the Nazarene, and/or Mount Vernon Nazarene University, I agree to release and hold harmless any staff and lay assistants of Nazarene Youth International Ministries, the General Church of the Nazarene, and/or Mount Vernon Nazarene University, from any and all claims, suits, costs and actions, of any kinds whatsoever, arising from their exercise of the power granted by this authorization.
Electronic Signature of Participant
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(
or Parent/Legal Guardian, if Participant is under 18 years of age
)
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