Dare 2 Share | Lake View Church

What:    Dare 2 Share Blaze 2010 in Chicago is a youth evangelsim conference featuring a full-production
              drama, powerful worship, Biblical sessions, hands-on evangelism training, interactive games, and an
              afternoon outreach experience.
Who:     This event is for grades 9-12. It will equip them to stand bold for Jesus in their school and community.
When:   Friday, March 19-20 2010
Where: Chicago
Cost:     $60 due by March 7th. It is recommended to bring $25 extra for meals

For more information, contact Wayne Hanson
Phone: (608) 873-9838
E-mail: wayne@lakevc.org

All fields require an entry. Please enter ‘x’ if something does not apply.

Student Info

Name: *

E-Mail:

Cell Phone:

Birthdate: *

Age: *

Grade: *

School: *

Home Info

Address: *

City: *

State: *

ZIP: *

Parental Info

From here on, all the questions should be answered by the parents.

Name of Parent or Guardian: *

Home Phone: *

Work Phone:

Cell Phone:

Family E-Mail:

Medical Info

Special Medications, Allergies, or Other Important Information:

Family Doctor/Name of Practice: *

Doctor's Phone: *

Insurance Company: *

Group Number: *

Policy Number: *

Other Emergency Contact: *

Include name, address, and phone number

I have read all of the consent form below.: *

I/We give consent for the name listed above to attend the Dare2Share Conference on March 19-20, 2010 in Chicago, Il.

I/We understand that in the event medical intervention is needed while under the care of LakeView Church, every attempt will be made to contact immediately the persons listed on this form. In the event I/We cannot be reached, I/We hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order an injection, anesthesia, or surgery for the student as deemed necessary.

I/We further agree to hold the licensed physician, the medical facility, LakeView Church and its representatives free and harmless of any claims, demands or suits for damages arising from the authorization and provision of such medical treatment.

I/We understand the nature of the event and do hereby release LakeView Church and its representatives from any liability due to accident or injury incurred by my child.

I/We understand all reasonable safety precautions will be taken at all times by LakeView Church Student Ministries and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold LakeView Church and its representatives liable for damages, losses, diseases, or injuries incurred by the subject of this form.

I/We agree to cover all costs if our student needs to be sent home for disciplinary reasons.

Unless otherwise noted, signing this form will release to LakeView Church the rights to photos, video or other images of this student for use in church publications.

By selecting YES, you agree to the above statementd and you are the legal guardian of the minor listed above.

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