VBS Outerspace Adventure - Hillsdale Assembly of God

Your Child(ren) Who Plan to Attend:

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Your Information

Name:
Address:
City: State: Zip Code:
Home Phone: Work Phone: Cell Phone:

Emergency Contacts & Information

#	Last Name	First Name	Phone	Relationship to Child(ren)
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Other Important Information

I give permission for my child(ren) to participate in the above named activity and release Hillsdale Assembly of God, its officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by my child(ren) or any member of my family in attendance, and I agree to defend and indemnify Hillsdale Assembly of God, its officers, emplyees, and agents from any liability or loss they might sustain by reason thereof. I further authorize Hillsdale Assembly of God to seek emergency medical care for my child(ren) should it become necessary.