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Description of 2017
These authorizations shall remain effective until December 31 2017 unless sooner revoked in writing delivered to said Agent. No oral representations statements or inducements have been made by or between the parties to this Agreement with respect to the subject matter of this Agreement apart from the matters set forth within this Agreement. I HAVE CAREFULLY READ THIS CONSENT TO TREATMENT OF MINOR AND RELEASE OF...
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2017

These authorizations shall remain effective until December 31 2017 unless sooner revoked in writing delivered to said Agent. No oral representations statements or inducements have been made by or between the parties to this Agreement with respect to the subject matter of this Agreement apart from the matters set forth within this Agreement. I HAVE CAREFULLY READ THIS CONSENT TO TREATMENT OF MINOR AND RELEASE OF LIABILITY AGREEMENT

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BETWEEN PARENT AND ORGANIZATION AND SIGN IT OF MY OWN FREE WILL. Parent s Name please print Parent s Signature Dated MULTI-MEDIA/PHOTOGRAPHIC RELEASE future events. I HAVE CAREFULLY READ THIS CONSENT TO TREATMENT OF MINOR AND RELEASE OF LIABILITY AGREEMENT BETWEEN PARENT AND ORGANIZATION AND SIGN IT OF MY OWN FREE WILL. Parent s Name please print Parent s Signature Dated MULTI-MEDIA/PHOTOGRAPHIC RELEASE future events. Photos of child

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shall remain the exclusive property of Cheney Church of the Nazarene and shall be used without notice or compensation.. Cheney WA 99004 509. 235. 6261 CONSENT TO TREATMENT OF MINOR AND RELEASE Herein Parent Herein Minor s Herein Organization Cheney Church of the Nazarene Herein Agent Cheney Church of the Nazarene and staff The above-named Parent of the Minor has entrusted the Minor into the care of

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the Agent an adult and a duly authorized representative of the Organization while the Minor participates in an activity sponsored by the Organization and for the welfare of the Minor. Cheney Nazarene Family Information and Release Form 2017 Please print legibly Father s Name Address City Apt/Unit State Zip Code Home Phone Number Cell Phone Work Phone Email Address Child/Children Information Child s Name Birth date MM/DD/YY Age

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School Grade Gender Medical Information Insurance Carrier Name of responsible party Family physician List all medical conditions List all allergies FoodOther - Policy Phone Drug- Medications required Special Accommodations needed Additional information needed to insure safety and care of child ren while in the care of Cheney Nazarene Emergency contact name other than parent Relationship Cheney Church of the Nazarene 338 W. Betz Rd. The Parent hereby agrees

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to fully pay all costs of medical or dental care incurred for the Minor by the Agent and the Organization under this authorization. Furthermore Parent voluntarily releases discharges waives and relinquishes all claims that they may have against Agent or Organization its officers employees and volunteers for any and all claims actions or causes of action for personal injury property damage or death occurring to Minor arising out

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of Organization s administration of or failure to administer medicine or medication to Minor save and except only those claims due to Organization s fraud or willful injury to the person or property of Minor. These authorizations shall remain effective until December 31 2017 unless sooner revoked in writing delivered to said Agent. The Parent hereby authorizes any hospital which has provided treat

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