GODSTOCK 2017 HEALTH AND RELEASE FORM Please feel free to use your own church’s health form or edit this one to fit your needs. YOUTH INFORMATION: Name: __________________________________________ Age: ______ Date of Birth: _____________________ Gender: _______

Shirt Size: s m l xl xxl xxxl

Address: _____________________________________________________________________________________ City, State, Zip: ______________________________________

Home Phone:__________________________

Student Cell Phone Number: ________________________________ Home Church: _________________________________________________________________________________ PARENT/GUARDIAN INFORMATION: Name: ___________________________________________ Address: _________________________________________ City, State, Zip: ____________________________________ Cell Phone:_______________________________________ Daytime phone: ____________________________________ Home phone: ______________________________________ Please read the following carefully and check (      

) those that you give your son/daughter permissions for:

I give permission for my Child to attend Godstock 2017 I give my son/daughter permission to participate in all activities at Godstock 2017 I give the adults accompanying my son/daughter or those adults on the youth board permission to seek medical treatment for my child in case of injury or illness. I give permission for my child to be transported to medical facilities as may be necessary. I authorize the physician/hospital staff to treat my son/daughter as they deem necessary an emergency. I have filled out an online waiver for Action City & Trampoline Park (find the link at sybnw.org/Godstock)

Medical insurance carrier: _____________________________________________________________ Policy number of medical insurance: ____________________________________________________ If your son/daughter is currently taking medications please list below. Medications: ________________________________________________________________________ Other Medical concerns that adults should be aware of: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _________________________________________________________________________ Parent /Guardian Signature: _________________________________________________ Date:________________ Every attempt will be made to reach parents in case of any emergency medical situation. This form authorizes supervising adults to act in the best interest of the child when parent cannot be reached. Thank you.