Who IS authorized to pick up your child? Name__________________________________________
Relationship to your child_______________________________________________________________
PLEASE NOTE YOUR CHILD WILL ONLY BE RELEASED TO THE PERSONS LISTED ABOVE.
Insurance Carrier______________________________________ Ins#____________________________________
Doctor's Name__________________________________________ Phone_____________________Office Location________________________________
Does your child suffer from asthma, diabetes, epilepsy, convulsions or seizures?_____________________________________________
Have they had any acute illness, injury, or surgery in the last three months?____________________________________________________
What medications does your child take?__________________________________________________________________________________
Other Medical Information _________________________________________________________________________________________________
In the event of an emergency where medical treatment is required I give permission
to WFF personnel to obtain the services of a licensed physician.
Please attempt to notify the person named below (in addition to parents) concerning any emergency.
1st Person to Notify________________________Phone# __________________________ Cell Phone#__________________________
2nd Person to Notify________________________Phone# __________________________ Cell Phone#__________________________
LIABILITY RELEASE
In consideration of the acceptance this form, I do hereby for myself, my heirs, Executors and Administrators,
waive release and forever discharge any and all claims with the rights for damages which I may have
or which may hereafter accrue to me against Wheat Field Fellowship (WFF) and their respective Officers, Agents,
Representatives, Successor, and/or assigns any damages and liabilities
which may be sustained and suffered by me in connection with, participation in, or traveling to and from any event(s).
***Should this registration form also function as registration for the Sunday School Year 2007 to 2008?_______________
If so, please read the paragraph below for additional information before signing this form.
From time to time, our Children's Church or Sunday School classes may go outside or play an active game.
Every precaution is taken to provide a safe and happy time for your children.
By signing this form, I understand that no amount of instruction, precaution, and supervision
will totally eliminate all risk of injury, and I release Wheat Field Fellowship and any authorized agents from any liability.
PHOTOGRAPHY RELEASE:
Note: We will take photographs during camp.
Since we value your child's safety, if we use these photographs, their names will not be used.

I hereby grant to Wheat Field Fellowship and their associated camps
the irrevocable and unrestricted right to use any publish photographs of me
and/or my spouse and children, or in which I may be included,
for any church publications, electronic reproductions (web sites)
and/or promotional materials or any other purpose and in any manner or medium.
In addition, I grant my permission to alter the same without restriction;
and to copyright the same. I hereby release the photographer and Wheat Field Fellowship
and their associated camps from all claims and liability relating to said photographs.

Parent/Guardian Signature________________________________ Date_____________________________