Name *

First Name

Last Name

Cell Phone

(###)

###

####

Do you speak Spanish? *

Yes

No

Where would you like to serve? (Check all that apply) *

We will do our best to honor your request.

Vision Clinic

Prayer and Evangelism

Face painting

Balloons for Kids

Craft for kids

Games/sports with kids

Family Photo ministry

Liability Agreement *

I hereby remise, release and forever discharge Circle of Concern, its employees, agents, servants and all other persons, firms and corporations whomsoever of and from any and all actions, claims and demands, whosoever which claimant now has or may hereafter have on account of or arising out of any accident, casualty and/or action which might happen while participating in programs/events. I further understand that there is no Worker’s Compensation or Accident Insurance furnished by Circle of Concern for such programs/events. I acknowledge that I am responsible for any and all personal medical expenses while participating in all programs/events, and agree to hold harmless Circle of Concern of any and all liability that may arise out of such participation.

Agree

Disagree

Family Member 1

First Name

Last Name

Check box only if under 18 years old

Under 18 years old

Family Member 2

First Name

Last Name

Check box only if under 18 years old

Under 18 years old

Family Member 3

First Name

Last Name

Check box only if under 18 years old

Under 18 years old

Family Member 4

First Name

Last Name

Check box only if under 18 years old

Under 18 years old

Family Member 5

First Name

Last Name

Check box only if under 18 years old

Under 18 years old