MEDICAL RELEASE

Name:________________________________________________________D.O.B._________________ Address:_____________________________________________________________________________ City:_______________________State________________________Zip:__________________________

I, ________________________________parent or legal guardian of _______________________________ do hereby agree and make public that I will not hold the Assembly of God Christian Center or any adult sponsor responsible for any accidents or injuries that may be sustained in connection with any A.G.C.C. youth activities. I understand that accidents do happen, and I will assume responsibility for any losses thereof. I also authorize emergency treatment for my child should it become necessary for the welfare of my child.

Please list phone numbers in case of emergency: Home:_________________________ Doctor (Name)________________________(phone)____________________ Work:______________________________ Drug Allergies:________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

ACTIVITY RELEASE

I, _______________________________ Parent or legal guardian of _________________________________ do hereby agree and make public that my teenager has my permission to attend activities with the A.G.C.C. Youth Minsitry.

1. Each teen is expected to stay with the group 2. Each teen is expected to obey all safety rules and dress code (attached) 3. There is to be no public display of affection By signing this form, as a parent, you are also agreeing that if your teen does not obey the rules of the activity, they are subject to the following discipline:

1. Parents will be called. 2. Teens will not be allowed to attend the next activity. 3. Parent will be called and informed to come and pick up their teen. (These steps will be left to the discretion of the person in charge)
(Any photocopy or facsimile of this page is as valid and legally binding as the original.)

Both Parents or Legal Guardian's Signatures:                            Teen's Signature:

________________________________________________         ___________________________

________________________________________________         Date:______________________