Youth Participant's Name

Home Phone

Cell Phone

Youth Participant's Email

Parent/Guardian Email

Address

Gender
MaleFemale
Birthdate

Current Grade
Recent Graduate12th Grade11th Grade10th Grade9th GradeOther
Estimated day and time of arrival on campus

Number of adults needing lodging

Asthma
YesNo
Medical Conditions / Allergies

Insurance Provider

Policy Number

I/We, the undersigned parent(s)/guardian(s), hereby consent to my child participating in
KMBC's “Climb Higher,” an event sponsored by Kentucky Mountain Bible College November 17-18, 2017. This permission includes activities both on and off the campus of Kentucky Mountain Bible College, as well as transportation to and from activities.

I understand and I acknowledge that Kentucky Mountain Bible College is providing transportation for my child to and from campus for the event. I acknowledge and assume the risk of this transportation for my child.

I hereby authorize Kentucky Mountain Bible College, it’s agents or employees to obtain such medical treatment as may be necessary in their judgment to ensure the health, safety, and well-being of my child. I understand and hereby agree to assume all risks which may be encountered on said activity, including activities and transportation preliminary and subsequent thereto.

I hereby agree to hold the transporting driver, Kentucky Mountain Bible College, their agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child, property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Kentucky and that if any portion thereof is held invalid; it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understood.

Parent/Guardian Name

Signature of Parent/Guardian (your initials will suffice as your signature)

Parent Home Phone

Parent Cell Phone

Date

Signature of Participant (your initials will suffice as your signature)