Parental Release Form

Name of Student
Date of Birth
MM slash DD slash YYYY
Parent/Guardian
First Last
Relationship to Student
Address
Street Address Address Line 2 City State ZIP Code
Email
Emergency Phone
Insurance Provider
Policy Number
Name of Agent
First Last
Known Allergies
PARENT/GUARDIAN APPROVAL & WAIVER OF CLAIM
I hereby approve of my child/teen to participate in the activities of the Wabash Church of the Nazarene Children’s Department and/or Youth Group and expressly waive any and all claims against the Wabash Church of the Nazarene, or the Church of the Nazarene denomination, or any of its districts, including the Northeast Indiana District, or its representatives (local, district, and/or global) because of injury or other damage that may be incurred to my child/teen whose name is listed below or any property belonging to them that is damaged at or during any and all church sponsored events. Furthermore I give permission to the church approved adult sponsors to act in my place in the event of a medical emergency until such a time as I am able to assume the responsibility myself. I also verify that the following insurance information is both true and accurate. Should any of the information below change between now and Dec 31, 2023, I will let the Wabash Church of the Nazarene know before allowing my child/teen to participate in any off-site events.
Parent/Guardian Signature*
- Agree
By clicking "agree," you agree to the above waiver.