Child's Information

Parent's Information

Dismissal & Emergency Contact Information (In case of ACCIDENT OR SUDDEN ILLNESS)

T-Shirt Sizes

I, being the parental/legal guardian and having legal custody of the children named on this form, minors, do hereby consent to said child(ren) participating in activities and related trips of The Pentecostals of Phoenix. I do hereby release, discharge and exonerate The Pentecostals of Phoenix and all persons acting as teachers or sponsors on said activities and trips from any liability whatsoever resulting from personal injury to said minor(s) which may occur at said activities or trips therewith. I do hereby certify that I assume full responsibility and liability for any acts committed by said minor(s) during activities and trips related thereto resulting in injury or damage to the property of another. I do hereby acknowledge that I understand this release is being relied upon by The Pentecostals of Phoenix and teachers or sponsors accompanying the children on said trips and activities; and without this instrument being executed by me, said minor(s) would not be permitted to attend field trips nor engage in activities related thereto.

I do hereby authorize The Pentecostals of Phoenix to contact directly the person named in this authorization, and do authorize the person and/or the physical or hospital listed below to render such treatment as may be deemed necessary in an emergency for the health of such child. In the event physicians, other persona named in the authorization or parents cannot be contacted, the church officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of the aforesaid child(ren). I will not hold The Pentecostals of Phoenix financially responsible for the emergency care and/or transportation for said child(ren).