Registration and Liability Release form for

Kern Park Christian Church for the

Jr. & Sr. Hi. Event:
Fire House Wednesday
St. Johns Christian Church — December 5, 2007
NAME/S:___________________________________________________________________________________
ADDRESS:___________________________________ PHONE:_____________________
CITY: _________________ STATE:_________ ZIP CODE: _______________
Person to notify in emergency:__________________________ Phone (if different than above)_____________________

COMMENTS OR MEDICAL INFO (Please, list all medications, allergies, medical conditions :
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

INSURANCE COMPANY:_______________________________________POLICY #:___________________

In the event of an emergency where medical treatment is required I give my permission to the Church staff or
sponsor to obtain the services of a licensed physician and I hereby authorize medical treatment. Please notify me
immediately concerning any such emergency.

I the parent/guardian of the above named student/s, give my permission and authorization is hereby given to ride in
church furnished transportation and
consent
do not consent to the use of any video images, photographs,
audio recordings, or any other visual or audio reproduction that may be taken of the subject of this release during
the activity/event to be used, distributed, or shown as Kern Park Christian Church deems necessary.

I the parent/guardian of the above named student/s, DO HEREBY RELEASE KERN PARK CHRISTIAN
CHURCH, their staff and officers from any responsibility in case of accident, illness, or injury during his/her atten-
dance.

Parent/Guardian Signature ________________________________ Date_______________________

Parent/Guardian Printed Name ________________________________

Please Tear off lower portion and Keep

Jr. & Sr. Hi. Event:

Fire House Wednesday
December 5, 2007
Location:
St. Johns Christian Church
8044 N. Richmond Ave Portland, OR 97203

Emergency Contact:
Brent Parker
Cell # 503-679-2960

Meet at Church at 5:30pm and will return by 8:30pm