Student's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent Cell Phone *

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I hereby release and agree to hold Harvest Lane Alliance Church harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Harvest Lane Alliance Church, or that may otherwise arise in any way in connection with any services received from Harvest Lane Alliance Church. I understand that this release discharges Harvest Lane Alliance Church from any liability or claim that I, my heirs, or any personal representatives may have against the church with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Harvest Lane Alliance Church. This liability waiver and release extends to the Harvest Lane Alliance Church youth group (S.O.L.E.) together with all members and the chartering organization (Harvest Lane Alliance Church). *

I agree.

Student Name *

First Name

Last Name

Student #2 Name

First Name

Last Name

Student #3 Name

First Name

Last Name

Student #4 Name

First Name

Last Name

Best phone number in case of emergency *

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