MEDICAL/LIABILITY

RELEASE FORM

who to contact
Summit and Woodside:
Brian Biedenbach

402-1176

Carroll and Maple Creek:

Ryan Weaver

571-2635

I have reviewed the rules of the activity and agree

that the subject of this release will abide by them.

Riverview and Crestview:

Dustin Shafer

651-7918

I consent to the use of any video images,

photographs, audio recordings, or any other visual
or audio reproduction that may be taken of the
subject of this release during the activity/event to
be used, distributed, or shown as Youth For Christ
determines.

Whitko and Indian Springs:

Dana Neuenschwander
229-8112

As parent/legal guardian of this student, I have

reviewed the information about this event and give
my permission for the subject of this release to be
involved in the overall activities connected with the
event.

I understand that in the event medical intervention

is needed, every attempt will be made to contact
immediately the persons listed on this form. In the
event I can not be reached, in an emergency, during
the activity dates shown on this form, I hereby give
my 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 my child as deemed
necessary.
I understand all reasonable safety precautions will
be taken at all times by Youth For Christ 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 Youth
For Christ, its leaders, its employees, and/or
volunteer staff liable for damages, losses, diseases, or
injuries incurred by the subject of this form.
_______________________________________
Parent/Guardian Signature
Date
_______________________________________
Emergency Contact #

CAMPUS LIFE

RED
EYE

Prairie Heights and Angola:

Mike Cain
668-0809
Westview:
Gerald Yoder

336-2664

Leo:
Ryan Miller

615-5063

Lakeland:
Troy Barker

463-6139

NORTHERN INDIANA
6427 Oakbrook Parkway
Fort Wayne, IN 46825
260-484-4551
www.yfcnorthernindiana.org

5
3
$
feb 20
6:30 pm Friday
Drop off at Summit Middle School
6:00 am Saturday
Pick up at Jorgensen YMCA

CAMPUS LIFE presents:

RED EYE
RED EYE is an all night event that brings Campus Life groups from all over Northeast Indiana to Fort
Wayne for an action-packed night jammed full with exciting events throughout!
Heres how it all goes down
All Campus Life groups will gather at Glenbrook Mall to kick the evening off. But then the night
kicks into a whole other gear

CAMPUS LIFE

RED EYE
REGISTRATION INFO:
Complete the form below and return it
with your $35 to your Campus Life
Director.
Name: _________________________________
School: _________________________________
Grade: _________ Shirt Size: S M L XL XXL
Address: ________________________________

LAZER TAG, BOWLING, ROLLER SKATING, BASKETBALL, SWIMMING,

DODGEBALL, CLIMBING WALL, PIZZA, and MORE

City: ______________ St: ______ Zip: ________

Phone: _________________________________
Emergency Phone: ________________________

as we visit Lazer X, King Pins Bowling, Roller Dome North, and the YMCA.
Students will be sleepy and ready to be picked up at your groups original meeting location and
designated time (see front of this brochure for those details.
TWO WAYS TO REGISTER (by FEBRUARY 16):
1- Complete, detach, and return the form to the right with $35 to your local Campus Life Director.
2- Online at www.yfcnorthernindiana.org. Just click on the News and Events tab to find the
registration link for Red Eye. Payment can be made securely online as well.

Parent/Guardian Name:
_______________________________________
Parent/Guardian Email:
_______________________________________
Pre-existing Conditions/Medical Issues/Allergies:
_______________________________________
_______________________________________

QUESTIONS:

Insurance Company: _______________________

The contact information for your local Campus Life Director is on the back of this form if you have
questions or need to reach us in the event of an emergency.

Policy #: ________________________________
Name of Policy Holder: ____________________