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This form is REGISTRATION OF STUDENTS only.
NO MONEY WILL BE COLLECTED. Finances should be turned in to the youth director of your local church.
Regular Registration Deadline: December 5, 2021 (Afterwards $30/student will be added)
NO REGISTRATIONS WILL BE ACCEPTED AFTER DECEMBER 12
PERMISSION TO PARTICIPATE: We (I) the parent(s) or legal guardian(s) of the student named on this form hereby grant our (my) permission for the student to participate fully in Breakaway activities December 27-29, 2021.
MEDICAL TREATMENT PERMISSION: We (I) authorize an adult Breakaway staff member, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned student pursuant to this authorization.
PHOTO & VIDEO RELEASE: I understand and grant permission for the student's image and voice to be captured in photography, video or audio during Breakaway, and that image shall be the property of Open Bible Central Region for promotional use.