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MOMENTUM JR HIGH EVENT - NOVEMBER 5TH/6TH, 2021

Activity: MOMENTUM JR HIGH CONFERENCE (LIVESTREAM) & GLOWZONE 360 (LAZERQUEST/MINIGOLF)

    
Date of Activity: NOVEMBER 5TH & 6TH, 2021
    
Details of the Activity:   Friday night at 7pm, students will participate in Momentum Jr High Conference (Via Livestream) The night will end at 9:30pm (approx). Saturday at 10:15, students will participate in day 2 of Momentum Jr High Conference (Via Livestream). Students will board a bus (driven by a licensed/insured krt-provided driver) to "GlowZone 360, for Lazerquest, Minigolf, Pizza & Pop. Students will return (by bus) to Kennedy Road Tabernacle to take part in Momentum Jr High Conference (Via Livestream) Activities may include (not limited to) Lazerquest, Minigolf, physical activities involving running, jumping and various degrees of physical involvement. Two slices of pizza & drink are included for lunch. Parents/Guardians to pick up student(s) at 5:30P.M.

Cost: $20.00 (Non-Refundable) - You will be re-directed to the payment link, upon I.D verification.
Dear Parent:
We are planning an activity as part of our programming that requires your permission prior to participation.  We have provided you the details of the activity and request that you complete and sign the permission form.  The safety of your child is our primary concern.  Precautions will be taken for their wellbeing and protection.

Student Participating
Minor
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First Student Name

First Name*

Last Name*

Phone*
First Student Age Acknowledgment*
First Student Date of Birth*
I certify that I am 18 years of age or older
First Student Information

Health Card Number *

Doctor's Name & Phone Number *
Does the participant have any allergies?*
No
Yes
Will the participant be bringing medication with them?*
No
Yes
Photo/Video Consent *
Internal Use Only
External Use Only
Both Internal & External Use.
First Student Signature*
Student Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Health Card Number *

Doctor's Name & Phone Number *
Does the participant have any allergies?*
No
Yes
Will the participant be bringing medication with them?*
No
Yes
Photo/Video Consent *
Internal Use Only
External Use Only
Both Internal & External Use.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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