EAGLES INTERNATIONAL TRAINING INSTITUTE

CHILDREN YOUTH TEENS

Health and Release Forms
INSTRUCTIONS: Please complete the following information requested below for each child attending the Gathering.
GENERAL INFORMATION
First Name ______________________________________ Last Name____________________________________________
Gender:

Boy Girl

Age______________

Grade Completed_____________

Address _____________________________________________________________________________________________
City ________________________________ State __________________________

Zip Code____________________

Home Phone __________________________________________Cell___________________________________________

E-mail: _____________________________________________________________________
Weight __________________

Height ____________________

Birthday ______/_______/_______

Parents or Guardians Names____________________________________________________________________________

Contact numbers ______________________________________________________________________________________

EMERGENCY CONTACT INFORMATION & AUTHORIZED PERSONS TO PICK-UP CHILD

List at least two (2) emergency contacts names (excluding parents/guardians listed above) and phone numbers of people
authorized to be notified if parents or guardians cannot be reached or are not available. [Please print clearly] Provide two
persons authorized to pick-up child. List at least two (2) persons authorized to pick-up and take child from the Gathering.
Name of Contact / Authorized
Pick-Up
1. Contact / Authorized / Both
2. Contact

/ Authorized / Both

3. Contact

/ Authorized / Both

Relationship to
Child

Address (Street, City, State, Zip)

Telephone Numbers

ALL INDIVIDUALS PICKING A CHILD up from the gathering must present a current form of photo id. This will be
required.
List any person NOT authorized to pick up child.*
1.

Is there a Custody Agreement Yes

No
*Copy of Court Order Custody Decree Must Be Attached

MEDICAL INFORMATION
Does this child require the use of any medicine? No _________
Yes_______ If YES, please complete the following:
Name of medicine ______________________________
Dosage__________________________
Times to be administered ______________________________________________________________
Children are not permitted to keep any medication in their sleeping areas. The Gathering nurse or authorized representative
will keep and administer all medicine.
Prescription Medications: Prescription medications must be in the original container labeled by the pharmacy or physician
with the childs name, instructions, including times and amount for dosages, physicians name and expiration date. The child
may receive medication only according to the written instructions of the health practitioner or the medical label.
Non-Prescription Medications: Non-Prescription medications shall be in the original container and labeled by the parent(s)
with the childs name and instructions for administration, including times and amounts for dosages.
CHILDS Name: ______________________________________

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Chaperones NAME __________________________________________

EAGLES INTERNATIONAL TRAINING INSTITUTE

CHILDREN YOUTH TEENS
SPECIAL WAIVER FOR CHILD TO CARRY EPI-PEN/ASTHMA INHALER
Due to the potential necessity for immediate medication distribution imposed by my childs life-threatening allergic response
or asthma, I hereby request that he/she be allowed to keep the appropriate, prescribed medication on his/her person while
participating in all EITI CHILDREN and/or (EICYT) activities.
The prescribed device is a:
Epi-pen
Asthma Inhaler
I understand that to qualify for this exemption, my son/daughter must be capable of safely storing the necessary asthma or
allergy medication on his/her person and using the medication as needed. I agree to release Set Free Ministries, the teachers,
instructors, volunteers, staff, helpers and all others associated, affiliated or aligned with the EITI CHILDREN and their
agents from all liability arising as a result of this waiver.
___________________________________ _______________________________________
Print Students Full Name
Parent/Guardian Signature

__________
Date

ALLERGIES
Please list and describe any allergies, type of reaction (i.e., rash, itching, etc.), special medical or physical conditions or
problems we should be aware of, including chronic health problems:

_____________________________________________________________________________________
_____________________________________________________________________________________
Please list any medications the above individual is now taking: __________________________________________________

*In emergencies requiring immediate attention, your child will be taken to the nearest hospital emergency room. Your
signature below authorizes a representative of EITI CHILDREN / EICYT to have your child transported to that hospital.

INSURANCE INFORMATION

PHYSICIAN INFORMATION

Insurance Company

Group #

Policy Holders Name

Policy #

Doctor Name

Phone

Street Address

City

Zip

EMERGENCY TREATMENT AUTHORIZATION

Please understand that emergency treatment will not be given to this child without parental consent.
This release gives permission for EITI CHILDREN/EICYT Kingdom Encounter Gathering nurse or authorized
representative to administer first aid. In the event of a serious illness or injury, if parents or alternative emergency
contacts cannot be reached, this form gives permission for the child to be treated at the nearest medical facility.
In case of medical emergency, I understand that every effort will be made to contact me or my emergency contacts. If I or
the emergency contacts (listed on this form) cannot be reached, I give permission to EITI CHILDREN/EICYT Director,
authorized representatives, or designated staff to secure the medical treatment deemed necessary for my child; including
hospitalization, injection, anesthesia or surgery. By my signature I hereby waive, release and hold harmless the teachers,
instructors, volunteers, staff, helpers, participants and/or all others associated, affiliated or aligned with EITI CHILDREN,
EITI, Set Free Ministries, and the respective officers, directors, instructors, leaders, assistants, agents, staff, volunteers and
representatives, individually, jointly or severally, from any and all liability for any injuries, death, or illness sustained and/or
incurred while attending camp at The Gathering and/or using any facilities associated with the Gathering as a result of my
physical condition or resulting from participating in any dance, exercise, game, or any of the other Gathering activities. I/we
hereby grant permission for emergency medical treatment and/or routine medical care by the EITI CHILDREN, EICYT, The
Gathering staff, a rescue squad, or private physician and/or hospital or emergency health care facility staff, under the same
CHILDS Name: ______________________________________

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Chaperones NAME __________________________________________

EAGLES INTERNATIONAL TRAINING INSTITUTE

CHILDREN YOUTH TEENS
circumstances as above if needed. Any such action will be taken in the best interest of my child and will be reported to me/us
as soon as possible. My signature waives and/or releases the teachers, instructors, volunteers, staff, helpers, participants and
all others associated, affiliated or aligned with EITI CHILDREN, EICYT, EITI, Set Free Ministries, and their representatives
and assigns from any and all liability and/or financial responsibility for any medical expenses incurred.
Signature of Parent/Guardian ________________________________________________ Date________________

PARTICIPATION PERMISSION / WAIVER FORM

This form must be read and signed by parent or guardian before a child can attend
EITI CHILDREN Kingdom Encounter Gathering
WAIVER
I understand that the teachers, instructors, volunteers, staff, helpers, participants and/or all others associated, affiliated and/or
aligned with EITI CHILDREN, EICYT, Eagles International Training Institute, Set Free Ministries, the Gathering Location
Facility and their representatives and assigns assumes no responsibilities for injuries, death or illnesses which my child may
sustain as a result of his/her physical condition or resulting from his/her participation in any dance, exercise, games, or other
Gathering activities. I also understand that they are not responsible for personal property lost or stolen while participants are
attending The Gathering.
I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries, death, illnesses, or
losses which may result from my childs participation in these activities. I also agree to indemnify and hold harmless the
parties from and against any and all actions, claims, demands, liability, loss, damage and expense of any kind, including
attorneys fees, arising from such claims.
I, for myself and my heirs, assigns, executors and administrators, next of kin, and successors, hereby waive, release,
discharge and hold harmless the teachers, instructors, volunteers, staff, helpers, participants and/or all others associated,
affiliated and/or aligned with EITI CHILDREN, EICYT, Eagles International Training Institute, Set Free Ministries, the
Gathering Location facility, and the respective officers, directors, instructors, leaders, assistants, agents, staff, volunteers and
representatives individually, jointly or severally, from any and all liability for / or claims of injury, illness, death, loss or
damage which my child may suffer, sustain and/or incurred while at the Gathering and/or using any facilities associated with
the Gathering as a result of my childs physical condition or resulting from his/her participation in these activities and I
recognize that EITI CHILDREN / EICYT representatives will make every reasonable effort to minimize exposure to known
risks associated with the Gathering.

EMERGENCY TRANSPORT PERMISSION. In case of emergency (Weather, Biohazard, etc.) where my child
needs to be transported, I give permission for the Gathering staff and/or their designated transport representative to transport
my child to a safe location.
I give permission to EITI CHILDREN, EICYT, EITI to use, without limitation or obligation, photographs, film footage, my
childs image, or voice for purposes of promoting the EITI CHILDREN / EICYT programs.

ACCEPTANCE
I acknowledge the Waiver and accept the conditions set forth above. Please sign and date as indicated below.

Childs Full Name: ____________________________________________________________________

(Please print)

Signature of Parent/Guardian:______________________________________________Date:________
CHILDS Name: ______________________________________

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Chaperones NAME __________________________________________