Cypress Creek Church Annual Parent Release Form

Child's Full Name

Date of Birth

Address

City/State

Zip Code

Home Phone #

Cell Phone #

Email Address

Parent or Primary Guardian's Information

Name (required)

Address

City/State

Zip Code

Home Phone #

Cell Phone #

Emergency Contact Person

Emergency Contact Phone #

Insurance Co. Name & Policy #

I, the undersigned, hereby release Cypress Creek Church, it's agents, employees, officers and servants, from any and all damages and injuries which may occur while (I/ my child) is participating in any/all Cypress Creek Church activities, on or off the premises during 2017. I also give my permission for Cypress Creek Church leadership to seek medical attention by a licensed physician in the event of a medical emergency. I certify that I have the legal authority to execute this release on behalf of (myself/ my child). I also agree, by signing below, that the above information is true and correct to the best of my knowledge.

Participant or Parent/Guardian Signature (if under 18 yrs. old)

Date