Name *

First Name

Last Name

Cell Phone *

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Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone:

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Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone:

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Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone: *

(###)

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Electronic Signature: *

First Name

Last Name

Electronic Signature: *

By selecting the "I Accept" button, you are signing this Medical Release electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

I Accept

Relationship: *

I am the...

Participant (I am over 18 years old)

Mother

Father

Legal Guardian

Consent: *

I consent to the medical treatment of my child in the case of injury and I cannot be reached, or if a delay in contact would be dangerous for him or her.

I agree to assuming all financial responsibility for any treatment or injuries sustained by my child while in the care of Radiant Church.

Date *

MM

DD

YYYY