The Worms of Baptist Tabernacle

This form is to be completely filled out and signed by a parent

or legal guardian before a student may participate in this event.

The Event:

Epic Board Game Battle Royale LOCK-IN

Friday, January 27 (9am) Saturday, January 28, 2012 (7am) Location: Baptist Tabernacle COST: $10

Students Name ___________________________________ Birthday ___/ ____ / ___ Current School Attended ______________________ Age_______ Grade_________

Physical Address __________________________ _________________ Apt. No. _____ Mailing Address (if different than above) ___________________________________________ City ________________________________________ Zip ________________________ Home Phone ________________________ Cell Phone _________________________

Parents Name(s)__________________________________________________________ Parents Cell Phone _______________________________________________________ Do any of the above have allergic reactions to any medications? Circle one: Yes No If so, please list their name(s) and the medication(s) to which they are allergic: __________________________________________________ I hereby give my permission for all listed above to attend this event and participate in all activities. I understand that my child(ren) will be under adult supervision. I further understand that in signing this permission slip, I release and hold harmless Collinsville Baptist Tabernacle, its trustees, officers, employees, and any volunteers from any liability, past or future, fully and completely. I authorize the executive staff or designated medical professionals to administer emergency medical assistance if I cannot be reached. I give my permission for my child(ren) to be admitted to the emergency room of a hospital for treatment by the hospital staff if needed and at the discretion of the assistant pastor or youth volunteer. Parent or legal guardian signature _______________________________ Date_ _______