Registration



Permission Slip & Medical Waiver

INSTRUCTIONS: If you are under 18 years of age, your parent or guardian must complete this section. If you are 18 years of age or older, you can complete this form for yourself.

Permission Slip for Any Church Related Function and Consent for Medical Treatment for Minors

The undersigned hereby gives permission for the above student to attend this with Bethany Bible Church. In the event there is an emergency involving my child, permission is hereby granted for Bethany Bible Church personnel to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in any state, and to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by any dentist licensed to practice in any state, and church personnel shall not be held personally liable.

(Typing my name in the space below serves as my digital signature.)

Please provide the following information:


Photography and Video Release for Minor Registrants

I acknowledge Bethany Bible Church and its representatives may take photographs and/or video of the minor who is being registered for this event and used by Bethany Bible Church for promotional needs, both in print and on the web. I know that in order to opt out I must contact Matt Burkholder at Bethany Bible Church at (602) 246-9788 or [email protected] with my opt out request. I have full authority to authorize this release.


Registration Payment Total

$85.00

Billing Information

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