Life Journey Community

STUDENT INFORMATION
Name*
First Middle Last
Date of birth*
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PARENT/ GUARDIAN INFORMATION
Name*
First Last
Relationship to Minor*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Best Contact Number*
Email*
Alternative Emergency Contact*
First Last
Emergency Contact's Relationship to Student*
Emergency Contact Number*

STUDENT MEDICAL INFORMATION
Insurance Provider*
Insurance Policy Number*
Primary Care Physician*
Primary Care Physician Phone Number*
Medical Concerns or Known Allergies*
Food Allergies/Restrictions*
Current Medications*
(Note: prescription & non-prescription medications must be turned into the trip leader and kept secure by him, her or camp staff.)

Medical Release
I give the above-named minor my permission to attend. In the event of illness or injury, I authorize emergency care by church leaders, camp staff, local emergency personnel or hospital, in case I cannot be reached for approval. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of the responsible adult should an accident or medical emergency occur during the time my child is in-route to, from, or during the activity, and the responsible leaders are unable to reach myself for authorization. I understand that the insurance of Life Journey Community Church and/or any other organization is secondary to my own primary coverage, for which I am responsible. I verify that all immunizations are current, and the above information is accurate and complete. I agree to notify One Eighty leadership of any changes to this information if any arise, prior to the activity.*

First Last
Date*

Injury and Liability Release
I will not hold or attempt to hold Life Journey Church liable for any loss or injury to person or property caused by any act or neglect of other persons or caused in any manner other than the willful or negligent act of LJCC, its agents and employees and will indemnify and hold LJCC harmless from any liability for damages or claims against LJCC arising out of or in any way related to any such loss, damage or injury. I release LJCC, including its trustees, employees and agents, from my child’s physical injury, including death or illness while at the activity. I/We will assume the risk associated therewith, whether known or unknown to me at this time. This release is also intended to include all my family, estate, heirs, personal representatives or assigns. I verify that my child is in good health and is capable of participating in strenuous activities, and when necessary, he/she will tailor the activities to those within the bounds of their physical health.*
First Last
Date*

Parent/Guardian Release
As PARENT/ GUARDIAN of the above student, by electronically signing below, I consent to this release and that my child agrees that this release shall be binding upon him/her as the parent or guardian of said minor and his/her estate, heirs, personal representatives and assigns. I have read, understand and agree on behalf of myself and my child to be bound by the terms of this agreement. I also agree to explain all risks associated with the minor and to help my minor understand their personal responsibility for adhering to the rules, guidelines and safety measures. By typing my full name below, I confirm that I am over 18 years old and I hereby attest that I have read and agree to the above waiver and release.*
First Last
Date*

Authorization of photo &/or likeness
I permit and authorize Life Journey Community Church and its employees, agents & personnel acting on its behalf to use my child's photograph or likeness for purposes related to the educational mission of the church, including publicity, marketing and promotion of its various programs. I understand this photograph or likeness may be copied and distributed by means of various media, including but not limited to video presentations, bulletins, mail-outs, signs, brochures & placement on Life Journey’s website. I understand that, although the church will endeavor to use the photograph or likeness in accordance with standards of good judgment, the church cannot guarantee that any further dissemination of the photograph or likeness will be subject to church supervision or control. Accordingly, I release the church from any and all liability related to dissemination of the photograph or likeness. I have read this document, understand & give consent to its contents.
First Last
Date

Student/Child Release – signed by the student attending
I understand that the risks of injury and illness from the activities involved are real and include the potential for permanent disability and death. While particular rules, equipment, and personal discipline reduce these risks, the risks of serious injury and illness still do exist. I knowingly and freely assume all such risks both known and unknown, even if arising from the negligence of others, and assume full responsibility and willingly agree to comply with the stated and customary terms and conditions for participation. If I observe any unusual significant concern preventing my participation, I will remove myself from participating in said activity and bring that to the attention of the nearest leader/adult immediately. I hereby release and hold harmless Life Journey Community Church, including its trustees, employees and agents, from physical injury, including death or illness while at the activity – whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law. I will not bring weapons, alcohol, drugs or any paraphernalia with me on this trip. Doing so will be grounds for me to be removed from the trip/activity and sent home, the cost being paid by my parent/guardian. By typing my full name below, I confirm that I am said minor and I hereby attest that I have read and agree to this waiver and release.*
First Last
Date*

One Eighty Release Form