GPM Junior Boys Lock-In and BBQ August 5th – 6th, 2011

The price of admission will be $10.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * __________________________________ ______________ ________________ Student’s Name Grade Date of Birth ____________________________________________________________________________ Address City Zip Code __________________________________ ______________ ________________ Parent’s Name Home Phone Cell/Work Phone __________________________________ ______________ ________________ Parent’s Name Home Phone Cell/Work Phone Emergency Contact (if and when the parents are not available) __________________________________ ______________ ________________ Name Phone Number Relationship I would like to send my child to GPM Lock-In and BBQ. In the event of an unforeseen accident during any part of the Activity, including transportation to and from the pick-up point, I hereby agree not to hold the church legally and/or financially liable (as detailed out in the attached Release Form). ________________________________________ ________________ Parent’s Signature Date

Glory Church of Jesus Christ Education Department

ACTIVITY RELEASE FORM

Release executed by _________________ (parent/guardian) for _______________________ (child/dependent) (hereinafter, “Child”) to Glory Church of Jesus Christ, 1801 S. Grand Ave, Los Angeles, CA 90015. In consideration of being permitted to participate in the GPM Junior Boys Lock-In and BBQ to and from the Glory Church of Jesus Christ and the designated location of its activities (hereinafter, “Activity”), between Aug. 5th-6th, 2011, I undersigned, in full recognition and appreciation of the dangers and hazards inherent in this Activity, including personal injury to which the Child may be exposed during the Activity, I do for myself, my heirs, and personal representative(s), and as a parent, guardian and/or representative of the Child hereby hold harmless, and release, and forever discharge GLORY CHURCH OF JESUS CHRIST, and all its pastors, elders, agents, representatives, employees, teachers and volunteers (hereinafter, “GCJC”), from and against any and all claims, demands, and actions, or causes of action from the Child’s participation in the Activity, including but not limited to causes of action which result from GCJC’s negligence and/or causes beyond the control of, and without the fault or negligence of GCJC, but excluding intentional acts of GCJC, during the period of the Child’s participation at aforesaid Activity. I also do for myself, my heirs and personal representative(s), and as parent, guardian, and/or representative of the Child hereby promises to defend and indemnify GCJC from and against any and all claims, demands, and actions, or causes of action from the Child’s participation in the Activity, including but not limited to causes of action which result from GCJC’s negligence and/or causes beyond the control of, and without the fault or negligence of GCJC, but excluding intentional acts of GCJC, during the period of the Child’s participation at aforesaid Activity.

MEDICAL CONSENT I, the undersigned parent or guardian of _____________________, give my consent for him/her to receive treatment for illness or injury, medication or immunization deemed advisable through the Glory Church of Jesus Christ’s health service, and to make the necessary referrals to other facilities, if necessary. I consent to any x-ray examination, laboratory test, anesthetic, medical or surgical diagnosis and hospital service that may be rendered to said minor under the general or special instruction of any licensed physician, whether such treatment or diagnosis or immunization is rendered at the office of the physician or at a licensed hospital or health department. It is understood that this consent authorizes the physician to exercise his/her best judgment as to what is best for the individual patient. Parent/Guardian Signature: ____________________________ Date: _____________________ Parent/Guardian Printed Name: _________________________ Date: _____________________