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Miami High School Mission Trip 2023 on Saturday, March 11, 2023 @ 8:00 AM

***The ATTENDEE in the portion above should be the STUDENT you are registering to attend the Miami High School Mission Trip.***

You will list parent email and phone numbers in the section below. 

*Grade for the 2022-2023 School Year:
*T-shirt Size:
*Primary Church Campus:
*Parent First Name:
*Parent Last Name:
*Parent Email:
*Parent Phone:
If your student has any medical conditions of which we need to be aware, or current medications they are taking, please provide details below.
If your student has any food allergies or dietary restrictions we need to be aware, please provide details below.

I give Rolling Hills Community Church permission to use my child's likeness in a photograph, video, or other digital media in any and all of its publications, including web-based publications, without payment or other consideration.
Rolling Hills Community Church will only use photos and video from the Miami Mission Trip privately: for internal publications, internal promotion of future trips, and on our Rolling Hills social media accounts. 


I, the undersigned, as the legal guardian of the above named Attendee, authorize the Designated Agents (as hereinafter defined) of Rolling Hills Community Church, 1810 Columbia Av, Franklin, TN 37064 (the “Church”), to consent to, and to execute any and all documents necessary for my child,  to be treated by a medical doctor or a medical facility, whether on an emergency or non-emergency basis, if such care be determined necessary for his or her care, health and general welfare during any activity or event associated with the Church. 

For purposes of this Medical Authorization and Release, the “Designated Agents” are defined to be the following:
1. John Jedneak
2. Sarah Fehl

Those persons identified as adult counselors and sponsors for an activity or event associated with the Church in an affidavit executed by any of the individuals listed above and presented with this Medical Authorization and Release at the time medical treatment is requested for the above-named Attendee.

This authorization shall remain in effect, from this date until 11:59pm, March 15 2023, unless sooner revoked in writing by me. I hereby release Rolling Hills and the Designated Agents from any claims, liabilities, demands, damages, rights and causes of action resulting or arising, directly or indirectly, from any consent or action taken by him or her pursuant to this Medical Authorization and Release.

*Parent Signature (Type in):