This is Temporary but WE are not.

Liability Release 2019

Uncategorized - October 2, 2015 - 0 Comments

(A PDF will be sent to you AFTER you complete the registration process)


Student Name__________________________________Male      Female

Street Address_____________________________City______________

State________Zip___________Home Phone______________________

Parents Names: Mother:______________________Father: ________________________

Parents Home Phone (if different from student)___________________

Mom’s Cell Phone___________ Dad’s Cell Phone_________________

In Case of Emergency and parents cannot be reached please contact:


Insurance Company:____________________________________________________

Policy Number:_________________________________________________________

Family Doctor:__________________________________________________________

Doctor City:__________________________Doctor Phone:_______________________

Current Medications:______________________________________________________

Date of Last Tetanus Shot? ______/________ (if not completed, tetanus shot will be given in case of emergency)

Medical History:


IN CASE OF EMERGENCY, I hereby give permission to the physician selected by the One21/ButlerSprings leadership to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child named on this card. I understand however, that every effort will be made to contact me in case of such an emergency and if possible, before any such medical treatment is administered.  I hereby release One21/ButlerSprings from any responsibility other than normal supervision and care. In case of accident, I will not hold Back2Back Ministries, One21, Butler Springs, or its Staff Members, Management, or Officers liable unless guilty of gross disregard for the safety and welfare of the student. I understand that if at any time my child(ren) shares any information that illustrates the potential for harm to themselves or others, all One21/Butler Springs staff  and volunteers are mandated by law to report.  

I give permission for any appropriate photographs/videos of my child to be used for future B2B/One21 promotional purposes.

____________________________ _________

Signature of Parent/Legal Guardian            Date

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