MSTC Release Form 2023

Basic/Emergency Contact Information

Participant's Name

Gender

Male Female

Date of Birth

Home Address

Group Leader Email

This address will receive a confirmation email

Participant Cell Phone

Name of Parent(s)/Legal Guardians

Parent Email

This address will receive a confirmation email

Parent/Guardian Cell Phone

Church Name

Medical Insurance Information

Does this participant have medical insurance?

Yes No

Name of Medical Insurance Company

Policy Number

Group Number

Is participant currently taking any prescription medicine on a regular basis? If so, please list.

Is participant allergic to any medication or food? If so, please list.

Parental/Guardian Medical and Liability Release Statement

I, the parent or legal guardian of the child (hereinafter “Participant”) listed on this form; certify that he or she has my full approval to participate in the 2023 Michigan Statewide Teen Convention (hereinafter “Statewide”). The Participant identified on this form understands that all Participants are expected to abide by the Statewide rules, (which I have read), and be directly responsible to the Statewide staff and leaders. Statewide’s staff and leaders assume responsibility for discipline during the convention, and if necessary, may because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for returning said Participant home.   Further, I do release and hereby agree to hold blameless, Statewide and its staff and leaders from any and every claim arising, or which may be asserted by me or by any member of my family by reason of participation in any activities associated with Statewide. Further, I do authorize the Statewide staff and leaders, in the event I cannot be reached by phone to give consent to a physician and/or hospital for emergency medical or surgical treatment while participating in Statewide. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment or for transportation home if necessary.   Further, I give Statewide permission to use photo and video taken during the convention in promotional materials.   Further, I hereby indemnify Statewide for any repair, replacement, reimbursement or compensation, due to damage to property, either real or personal, caused by my child.   Statewide will not be responsible for personal injury or loss of valuables of any kind.  My consent and signature are given below. I have read and agree to the information given in this entire form.

Date Signed

Description

November 3-5

Please fill out this form for every participant that'll attend the Michigan Statewide Teen Convention 2023

MSTC Release Form 2023

Description

Please Fix the Following