* 1. Child's Name

* 2. M/F

* 3. Address

* 4. Contact Info

* 5. Birthday

* 6. Age

* 7. Grade

* 8. Emergency Contacts

* 9. IN CASE OF EMERGENCY:  I hereby give authorization to an adult leader of the events within this year, as agent for me, to consent to an X-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital.  I expect to be contacted as soon as possible.

            This is also to certify, to the best of my knowledge, that the above named has no physical handicaps or illnesses (except as noted on this form).  I hereby release New Hope Christian Church of Crawfordsville, IN, its staff, and sponsors from responsibility and liability for any injury or illness that the above named may sustain during church sponsored events/activities.

* 10. Medical Information