Stuck in the Middle Individual Release Form

Event that you're attending *

Church/Organization Attending With *

Group Leader's Name (Your youth pastor or whoever is in charge of the group) *

Group Leader's Email (this MUST be correct for them to receive your registration) *

Participant's Name * First Last

Gender

Participant's Email

For students only

If you are filling out this form for an adult leader, please skip to Medical Information. If you are filling this out for a student, this section is required.

Participant's Grade in School

Name of Parent/Guardian with whom student lives First Last

Parent/Guardian's Email

Medical Information

Health Insurance Provider *

Policy Number

Physician's Name

Allergies, Known Medical Conditions, Current Medications

Emergency Contact * First Last

Please Read and enter your name below as your digital siignature

I, the parent or legal guardian of the student or listed on this form, do hereby certify that he/she has my full approval to participate in the Stuck in the Middle event. The child identified on this form understands that all students are expected to abide by the program rules and be directly responsible to the program director for Stuck in the Middle. I understand that Stuck in the Middle reserves the right, if necessary, to ask a student or adult to leave the event due to misconduct or disobedience to the rules of the event. If asked to
leave for such reasons, I understand no refund will be provided. Furthermore, in such instance I will assume full responsibility for returning the student home.

Further, I do release and hereby agree to hold blameless Stuck in the Middle and it’s employees and agents from any and every claim arising, or which may be asserted by me or by any member of my family by reason of participating in any activities associated with Stuck in the Middle programs. I also release and agree to hold harmless the lessor of properties on which the Program is held.

Further, I do authorize the minister or sponsor of this activity or any Stuck in the Middle senior staff member, 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 at this convention. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment.

Further, I give Stuck in the Middle permission to use photo and video images of my child taken at this event in any promotional or other Stuck in the Middle related materials.

Further, I do certify that said child is covered by adequate accidental insurance. My consent and signature is given below. I have read and agree to the information given in this entire form.

Digital Signature of Parent/Legal Guardian * First Last

Adult leaders, please sign your name here if you are over 18.

Wufoo

For students only

Medical Information

Please Read and enter your name below as your digital siignature