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High School Winter Retreat on Friday, February 19, 2021 @ 4:00 PM

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125.00
*Attendee's Birthdate
*Grade:
Campus:
*Gender:
Please list up to two names of any roommate preferences:
*Parent/Guardian's Full Name
*Parent/Guardian's Email
*Parent/Guardian's Phone Number

Emergency Contact #1

*Full Name
*Phone Number
*Relationship to Student

Emergency Contact #2

Full Name
Phone Number
Relationship to Student

Insurance Information

*Policy Holder's Name
*Relationship to Student
*Insurance Company
*Group or Policy Number
*ID Number

Health Information

*Please list all known medical conditions, including food allergies and/or drug allergies. In addition, include any over-the-counter and prescription drugs taken regularly: 
*Physician’s Name
*Physician’s Phone Number
If your student has any dietary restrictions, please list them below:
*Does your student carry an EpiPen?
*Does your student carry a rescue inhaler?
*Does your student have any mental or emotional issues the staff should be aware of?
*Are your student’s immunizations up-to-date?
If they are not current, please explain:
In the event of an emergency and I cannot be reached, I authorize Granger Community Church, its agents and employees to contact and secure medical attention for my child. Also, I authorize Granger Community Church, its agents and employees to administer basic first aid to my child/children as necessary.
The participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury that could occur with the participation in the activity described above. Except for gross negligence on the part of Granger Community Church, the participant (or parent/guardian) accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent/guardian) releases and agrees to hold harmless Granger Community Church and its representatives from any liability, injury, damage loss, accidents, delay or irregularity related to the undersigned individual’s planned participation in the activity.

The participant (or parent/guardian if participant is a minor) also assigns to Granger Community Church the rights to any photos, videotape and/or sound recordings made of me by or for Granger Community Church. I hereby authorize the reproduction, sale, copyright, exhibition and/or distribution of said photos, videotapes or sound recordings without limitation or compensation.

Granger Community Church COVID-19 Policies and Exposure Notice:
I agree to abide by any policies and procedures established by Granger Community Church for participation in this event, including policies and safety measures intended to mitigate exposure to COVID-19 (novel coronavirus). Moreover, I agree to notify Granger Community Church immediately if I learn that I have, or may have been, exposed to, or diagnosed with, COVID-19 and that I will immediately cease my participation in this event upon receiving such information. Granger Community Church leaders will do their best to adhere to local and national health guidelines for proper social distancing and gathering in groups, but I understand I am participating in this event at my own risk.
By typing my name in this box I am acknowledging my signature:
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