Redeemer Lutheran Church 7755 Greenstone Trail Fort ...

[Pages:2]Redeemer Lutheran Church 7755 Greenstone Trail

Fort Collins, Colorado 80525

PERMISSION / WAIVER FORM Name of participant (please print): ______________________________________________________ Parent(s) and/or legal guardian(s) if participant is a minor (please print): _______________________

___________________________________________________________________________________

Address ___________________________________________________________________________________

Street

City

State

Zip

Home Phone (_____) ________________Cell or Work Phone (____) __________________

Age of participant: _________________

Birth Date (mm/dd/yy): _____________________

Activity Date: Night to Shine, February 2017:

On February 10, 2017, Redeemer Lutheran Church, in collaboration with Grace Community Church in Loveland, Mosaic of Northern Colorado, and Crossroads Covenant Church in Loveland, will host Night to Shine. Night to Shine is a worldwide movement sponsored by the Tim Tebow Foundation that provides an unforgettable prom night experience for people with special needs. It is being hosted simultaneously on that Friday by more than 300 churches in all 50 states and 9 countries. The event will require more than 70,000 volunteers and on that one night more than 30,000 people with special needs, ages 14+, will attend a prom around the world. We ask that all volunteers receive a background check unless they are under the age of 18. Volunteers under the age of 18 will need a signed permission form from their parents and volunteers under age 16 must be accompanied by a parent the night of the event.

The main event will take place at Redeemer Lutheran Church on February 10, 2017. Volunteer training will take place at Redeemer Lutheran Church on January 21st and 26rd, and on January 28th. Specific pre-event preparations for participants on the event date will take place at Grace Community Church and Mosaic of Northern Colorado. In addition all four locations will prepare their facilities for this event on various dates leading up to and including the date of the main event on February 10, 2017.

This permission/waiver form covers all dates and times at all four locations that are associated with this Night to Shine event.

Functions and Activities

I / We, herby, give permission for my child listed above to participate in the event(s) listed above. I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness, or even death.

I / We hereby give permission for the representatives of Redeemer Lutheran Church, Grace Community Church, Mosaic of Northern Colorado, and Crossroads Covenant Church to administer necessary First Aid and Medical aid to our child when deemed appropriate. I realize that every effort will be made to contact me before any emergency treatment, if the leaders of Redeemer Lutheran Church, Grace Community Church, Mosaic of Northern Colroado, and/or Crossroads Covenant Church cannot reach me; I give them permission to admit my child into the care facility at that location. I release the agents of Redeemer Lutheran Church, Grace Community Church, Mosaic of Northern Colorado, and Crossroads Covenant Church from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. I / We hereby give permission for our child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church, Grace Community Church, Mosaic of Northern Colorado, Crossroads Covenant Church and the Tim Tebow Foundation.

Please Provide Insurance Information and Medications/Allergies

Participants/Parent(s) Signatures: _______________________________________________________ Date: ___________

_______________________________________________________ Date ____________

Allergies (including food): Current Medications: Surgeries /Major Injuries: Insurance information:

Company _______________________________________________________________

Policy Number _____________________________ Phone number _________________

Insured Party ______________________________ _____________________________

*Please include a copy of your insurance card below If there are any past medical surgeries or major injuries please list them on below or on an attached separate page. Please also list current medications that the participant is using specific instructions, along with any allergies.

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