Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Student Cell (if applicable)

(###)

###

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Birthdate *

MM

DD

YYYY

Gender *

Male

Female

Permission *

I give my permission for my child to attend the Gainesville Aid Project during the session from June 9-13, 2021. I give permission for the G.A.P. Director, a G.A.P. staff member, or Youth Leader to sign for medical treatment in the event that I can not be reached. I will not hold Antioch United Methodist Church, Antioch Campground, Antioch Campground Trustees, G.A.P, or the G.A.P. staff liable or responsible for any accident or injury occuring during this time. I give permission for images of my child captured during the Gainesville Aid Project through video, photo and digital camera, to be used solely for the purposes of the Gainesville Aid Project promotional material and publications, and waive any rights of compensation or ownership thereto.

First Name

Last Name

Today's Date *

MM

DD

YYYY

Non-Parent Emergency Contact *

First Name

Last Name

Non-Parent Emergency Contact Phone *

(###)

###

####

GAPper's Pledge *

I promise to abide by all the rules and regulations of the GAP program and always operate by the rule of "Safety First."

First Name

Last Name

Today's Date *

MM

DD

YYYY