REACH REACH REACH REACH REACH REACH
 

REACH Release of Liability

indicates a required answer

We, the parents/legal guardians of the children listed below, acknowledge that there is some risk of injury involved while participating in the Racine Education After Christ’s Heart Community Day. We recognize that the teachers and leaders are volunteers and are not professionals. We release REACH, its leadership and volunteers, and Racine Bible Church from liability for any injuries that may result from being on the premises or participating in these classes.

 
1. *

Date: 
2. *

Parent(s) Full Name: (First and Last Name Please!)

 
3. *

Phone Number:
4. *

Parent(s)/Legal Guardian Agree to Reach's Release and Liability Statement above:

 
I Agree
5. *

Child's Name:
6. 

Child's Name:
7. 

Child's Name:
8. 

Child's Name:
9. 

Child's Name:
10. 

Child's Name:
11. 

Child's Name:
12. 

Child's Name:
13. *

Insurance Company:
14. 

Policy #:
15. 

Group #:
16. 

Physician:
17. *

Emergency Contact(If parent cannot be reached):
18. *

Relationship to child:
19. *

Phone Number:
20. 

Please list names of anyone who is approved to drop off or pick up your child from community day:
21. 

Please list any allergies or medical conditions that we should be aware of (please also state if your child carries an Epipen with him/her):