Student's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Phone *

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Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

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Name on Insurance Card *

First Name

Last Name

Physician *

First Name

Last Name

Physician Phone *

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Please Sign and Date *

I hereby give my permission for myself or my child to participate in an activity organized by Southpoint Fellowship. I hereby release, hold harmless and absolve Southpoint Fellowship, their staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Southpoint Fellowship staff or any adult counselor acting on behalf of Southpoint Fellowship with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child’s medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that Southpoint Fellowship may tape or photograph my child and record his or her voice during their participation in the activity. I agree that Southpoint Fellowship will be able to use them, in whole or in part, whether in original or modified form in any manner or media, including without limitation, for the purpose of advertising, promoting, and publicizing Southpoint Fellowship, whether during the activity or thereafter. I hereby release and discharge Southpoint Fellowship and all affiliated entities from any and all claims, demands, or causes of action that I have in connection with the use and exercise of the rights granted in this release.

First Name

Last Name

Date *

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