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Please read the entire form carefully. Thank you!
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Family Name
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Address
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City
State
Zip Code
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Phone Number
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Email
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PLEASE LIST ALL FAMILY MEMBERS THAT WILL BE ATTENDING FAMILY RETREAT
Name of Family Member
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Gender
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Age
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Name of Church you attend
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Pastor's Name
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Pastor's Phone Number
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Pastor's Address
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LIABILITY RELEASE
My family and I choose to participate in camp activities and understand we do this at our own risk. We will not hold SIMC liable for injury or loss of property.
Signature
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PHOTO RELEASE
I give my consent to use my or my child/children's photograph, likeness or image, whether in still frame, voice or video format by World Gospel Mission/American Indian Field/SIMC in publications, promotional brochures, video presentations, on the world wide web and in display formats.
Signature
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MEDICAL RELEASE
I give permission for first aid treatment to be given to me or my child/children if deemed advisable by the SIMC staff.
Signature
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Date
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Insurance Company
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Policy Number
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Allergies:
Do you or your child/children have any know allergies?
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No
If YES, please explain
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PLEASE LIST ANY MEDICAL CONDITIONS OR RECENT ILLNESSES THAT WE NEED TO BE AWARE OF:
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Emergency Contact
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Emergency Contact Phone Number
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