Name ______________________________________
What event(s) are you registering for?___________________________
Address_________________________________________ City____________________________ Zip___________ Grade__________ School___________________________

I hereby release LIGHT OF THE DESERT and its employees (volunteer and paid) from all liabilities that may occur while participating during our Youth Group events. I give permission for my child to go on this trip and certify that my child is in good health, free from communicable disease, and is able to participate in this activity. If I can not be contacted and there is a medical and/or surgical emergency, I give permission to the physician/hospital selected by our Light of the Desert leadership to hospitalize and/or secure proper treatment for my child (as named above). I will be responsible for all medical bills. I also recognize that if my child does not cooperate with our leadership team, that I would be notified of the problem and am expected to pick him/her up at our event.

Parent/Guardian Signature___________________ Date____________
Home Phone________________________________
Emergency Phone_______________________________
Insurance & policy # ______________________________________