180 After Hours

Parent Information

Insurance Information

Student Information

Medical History

Consent and Release

I hereby authorize the participation of the above-named child(ren) in activities of Grace Community Church. In consideration of Grace Community Church providing these activities, I, on behalf of myself and other parents and guardians of the minor(s), do hereby release Grace Community Church, its officers, employees, agents, and members of the Board of Elders from all claims and causes of action by reason of any injury which may be sustained as a result of these church activities, whether on the church premises or on the way to or from these activities. I agree to direct my child(ren) to cooperate and to conform with directions and instructions of personnel of the organization in charge of these activities. Should my child(ren) not do so, and should those leading an activity believe it necessary, I will come and remove my child(ren) from the activity as soon as possible after being called by a staff representative for that purpose. I understand and agree to leadership having access to my child(ren)'s room when necessary.

I hereby give my permission to the physician, nurse, or dentist selected by Grace Community Church to secure medical or dental aid as required for illness or injury under a physician's orders, including transportation to and from necessary facilities. As a participant, I understand Grace Community Church is not obligated to carry any insurance to cover those medical and/or dental expenses. If such insurance is carried, coverage will be provided only for expenses in excess of the limits of the participant's insurance. I understand that my personal insurance is my primary coverage. This authorization shall remain effective until revoked in writing delivered to Grace Community Church.

Payment Information

If you are registering more than 1 student from the same family, please select the payment option that corresponds to the total number of siblings attending.