Sanctus Penitas Form

Student Name*

First Last

Grade

Student Name #2

First Last

Grade

Student Name #3

First Last

Grade

Address*

Street Address City State ZIP Code

Phone*

Email*

Name of Parent or Guardian*

First Last

Emergency Contact Phone Number*

Insurance Company Name*

Insurance Company Phone Number*

Name of Primary Policy Holder*

Name of Insurance Policy Number*

By checking the box below, I hereby give permission for any and all medical attention to be administered to my child/children in the event of accident, injury, sickness, etc., under the direction of The Sanctuary Fellowship, if I am unable to be reached. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given below. It is my intention, by this instrument, to exempt and release The Sanctuary Fellowship from all liability whatsoever for personal injury, property damage, or wrongful death arising from any participation in this event. I hereby personally assume all risks in connection with said event, for any harm, injury, or damage that may befall my child/children while they are participating in this event, including all risks connected therewith, whether foreseen or unforeseen. By checking the box below I agree to all terms and conditions listed above. I confirm that I am the parent / guardian of the student(s) listed above. I understand and acknowledge that checking the box below acts as my electronic signature.*

By checking this box I am agreeing to the terms and conditions listed above.

Registration Fee*

This cost includes all transportation, meals, lodging and admission into conference.

Total

$0.00

Sanctus Penitas Form

Hot Hearts 2018