Title:                    Rev.    Dr.    Mr.    Mrs.    Ms.    Miss.    Master.

  Full Name:        Over 18:    NO YES

  Street Address:       Apt No.

  City:      State:   MD DC VA NC SC PA                 Zip:  

  Daytime Telephone:          Evening Telephone:    

  Email Address:     (If No email address, enter NONE)

  Church Name:            Pastor:   

  Current Position held in Church School:    Select Only One Student Superintendent Teacher Helper Secretary Chorister Other  No. of  Years:    0 1-2 3-5 5-10 >10  

It is MANDATORY for all participants to complete the Permission Form below.

I permit my son/daughter and myself to participate in the 2007 Capitol District Church School Convention.  I agree in the event of an injury to my son/daughter or myself during participation, any medical treatment we must undergo as a result of said injury will be covered by my own medical insurance coverage or my own responsibility.

Therefore in the event of injury to my son/daughter or self, we release from responsibility the Capitol District Church School Council, its subsidiaries and all members connected to this event.

We understand that in the event medical treatment is required, every effort will be made to contact the legal parent(9s) or guardian(s).  However, if the parent(s) or guardian(s) cannot be reached, permission is granted to the Capitol District Church School Convention staff to seek the services of a licensed physician to provide necessary care to ensure the safety of the participant.

Health Warranty: I warrant and represent that my son/daughter or self have no disability, impairment or ailment that prevents us from engaging in active or passive exercise.  I make this representation knowing that the Capitol District Church School Council and its subsidiaries (Organization) will rely upon it in allowing us to participate in Organization activities.

Waiver of Claims: I expressly agree that my participation or my son's/daughter's participation in the Organization activities are undertaken at our sole risk and that the Organization's owners, managers, employees and agents (Management) shall not be liable for any damages or injuries to myself, my son/daughter or my property or be subject to any claim, demand, or cause of action, including for any injury or damage resulting from the negligence of the Organization, its Management or other organization participants.

Release of Organization: I, on behalf of myself, my son/daughter, my executors, administrators, heirs, assigns and successors, do herby fully and forever release and discharge the Organization and it's Management from all such claims, demands, injuries, actions or causes of action.

Consent: I consent to pictures being taken of my son/daughter or self by the Organization and understand that such pictures will become the property of the Organization.  The Organization may use them for promotional purposes without the payment of fees or other compensation to my son/daughter or self.

Minors:  Where the participant listed above is a Minor (under 18 years old), as the minor's parent or legal guardian, expressly make the Health Warranty and agree to the Waiver of Claims, Release of Organization and Consent provisions contained above.  I authorize the Organization and its Management to obtain medical treatment for my dependent minor.

  Parent/Guardian Consent Form:

  Birth date of Minor:         Special Needs/Allergies/other medical info:

  Emergency Contact Person:           Emergency Contact Phone Number:     

  I have read the above and agree to its terms by the affixing of my name(s) below  Yes      No

  Name of Registrant, Parent(s) or Guardian(s)                  Today's Date: