Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

It is the understanding of this group member& his/her parents or guardians that in the event a medical emergency should arise requiring medical care to be given immediately, the group member & his/her parents or guardians authorize that such medical treatment shall be given & consent to such treatment at a hospital or other health care facility, or initially by group sponsor, if necessary.

_________________________________________________________ __________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

In consideration of being permitted to participate in the programs & activities of the Cumberland Presbyterian Church of Marshall, and in consideration of being provided transportation in this program where transportation may be provided by the church, I assume all the risks and hazards incidental to the conduct of the program and knowingly release, absolve, indemnify, & hold harmless the Cumberland Presbyterian Church in Marshall, Texas, their members & trustees, the Session, the Diaconate, Committees, & Staff, as well as the organizers, sponsors, workers, & all others acting in behalf of the Cumberland Presbyterian Church of Marshall or its programs & activities from all claims that might result from injury, damage, or death.

If I am the parent, legal guardian or custodian of any minor participating in the programs & activities of the Cumberland Presbyterian Church of Marshall, I knowingly release, absolve, indemnify, & hold harmless the Cumberland Presbyterian Church of Marshall, in Marshall, Texas, their members & trustees, the Session, the Diaconate, Committees, & Staff, as well as the organizers, sponsors, workers, & all others acting in behalf of the Cumberland Presbyterian Church of Marshall or its programs & activities from all claims that might result from injury, damage, or death.

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date _____ _________ _______

(month) (day) (year)

Signature ________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_______________________________________________ __________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date _______ _______ ______

(month) (day) (year)

Signature________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________ _____________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date__________________________________

(month) (day) (year)

Signature______________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_______________________________________________ _______________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________ _________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date__________________________________

(month) (day) (year)

Signature_______________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

____________________________________________________ _________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date___________________________________

(month) (day) (year)

Signature_________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: PNM11779294001 Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

___________________________________________ ______________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________________

(month) (day) (year)

Signature_________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

__________________________________________ ________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________-______________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

____________________________________________ ____________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date____________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

______________________________________________ _________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date_________________________________________

(month) (day) (year)

Signature____________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

____________________________________________ _________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date___________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_____________________________________________ _________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date___________________________________

(month) (day) (year)

Signature_________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________ __________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date__________________________________

(month) (day) (year)

Signature_________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________ _________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date_____________________________________

(month) (day) (year)

Signature_________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_________________________________________________________ __________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date___________________________________

(month) (day) (year)

Signature _________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________Lisa Sanders___________________________ _________11/7/07_________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date_____11_________7__________07__________

(month) (day) (year)

Signature____Lisa Sanders__________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

____________Mark Horner__________________________________ ___________11/5/07________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date____11___________5_________2007

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

___Susan Mosley____________________________________________________11/4/07_________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date____11___________4_________07_________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_______Lisa Sanders_________________________________________11/7/07__________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date____11___________5____________2007______

(month) (day) (year)

Signature______Lisa Sanders____________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List medications

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_____Mireya Brennan____________________________________________________11/10/07_________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________Cecilia Albarracin___________________________________________11/09/07_______________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date____11___________09_________2007________

(month) (day) (year)

Signature_____Cecilia Albarracin___________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_________Alexander Regal_____________________________________________11/10/07___________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

______NAEELA S. VITLALABER_____________________________________11/10/07_________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

__________Patricia Nunez___________________________________________11/10/07__________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

______21, did not need______________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

____________Not a minor_________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date_____11________10________07____________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

______Oscar Vallejo______________________________________________11/10./07__________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date____11__________10___________07_______________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

__________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date__________________________________

(month) (day) (year)

Signature____Juan Romero (probably, but cannot read____________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_______________________________________________ _____________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________

(month) (day) (year)

Signature_____________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

______________________________________________________________ _______________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date__________________________________

(month) (day) (year)

Signature_______________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature_____________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

_____Mark Horner__________________________________________________11/5/07_________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787

RELEASE AND HOLD HARMLESS AGREEMENT

I understand that this Release and Hold Harmless Agreement pertains to all programs & activities of the church, including those where the church may provide transportation.

This Release and Hold Harmless Agreement shall remain in effect until revoked by me in writing.

Date________________________________________

(month) (day) (year)

Signature__________________________________________________________________

If the signature is by a minor’s parent, legal guardian, or custodian, please complete the following:

MINOR’S NAME:

MINOR’S ADDRESS:

TELEPHONE NUMBER:

MINOR’S DATE OF BIRTH:

WORK NUMBER OF PERSON SIGNING THIS FORM:

CELL PHONE NUMBER OF PERSON SIGNING:

Medical Information, Registration and Consent Form

Name: Address: Zip:

Home Telephone: Participant’s Cell Phone: Age: Grade:

Church: T-shirt Size:

Parent (s)’s, Guardian’s name(s):

Cell Phone of Parents: Participant or parent E-mail:

If unable to be reached, who else may be called? Relationship?:

Their Telephone: Their Cell Phone:

Please list all allergies or reactions you may have to the following things:

List foods: List Medications:

List insect or natural elements:

Any special medication that you might be taking or need:

Each person should determine whether his/her medical insurance coverage includes coverage for medical problems that occur away from home. If so, please state as follows:

Name of insurance company: Policy #: Group #

Name of family physician:

Physician’s Address: Telephone:

MEDICAL CONSENT & AUTHORIZATION:

________________________________________________________________________________________________

Parent or Guardian’s Signature Date

Make checks payable to Cumberland Presbyterian Church Youth Ministries

Bring or Mail to: CPC of Marshall

501 Indian Springs Road

Marshall, TX 75672

903-935-3787

cpcmtx@marshalltx.ocm

P.O. Box 1303

Marshall, TX 75671

(903) 935-3787