Name of the student you are registering.
What Church is your student registering with?
Name of Parent/Legal Guardian
Parent's Email
Parent's Phone Number
Does your Student have Medical Insurance?
Is your Student taking any Medications?
Does your student have any allergies?
Legal & Medical Release
I, the parent or legal guardian of the child (hereinafter “Participant”) listed on this form; certify that he or she has my full approval to participate in the 2025 Michigan Statewide Teen Convention (hereinafter “Statewide”). The Participant identified on this form understands that all Participants are expected to abide by the Statewide rules, (which I have read), and be directly responsible to the Statewide staff and leaders. Statewide’s staff and leaders assume responsibility for discipline during the convention, and if necessary, may because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for returning said Participant home.
Further, I do release and hereby agree to hold blameless, Statewide and its staff and leaders from any and every claim arising, or which may be asserted by me or by any member of my family by reason of participation in any activities associated with Statewide. Further, I do authorize the Statewide staff and leaders, in the event I cannot be reached by phone to give consent to a physician and/or hospital for emergency medical or surgical treatment while participating in Statewide. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment or for transportation home if necessary.
Further, I give Statewide permission to use photos and videos taken during the convention in promotional materials.
Further, I hereby indemnify Statewide for any repair, replacement, reimbursement, or compensation, due to damage to property, either real or personal, caused by my child.
Statewide will not be responsible for personal injury or loss of valuables of any kind.
My consent and signature are given below. I have read and agree to the information given in this entire form.
Signature
Today's Date
