Please fill out this insurance form in the event your students need immediate medical help.

Agree and Acknowledge

I understand and acknowledge that if I proceed to register online and to sign the waiver electronically, that, under the Electronic Transactions Act, such electronic registration and electronically signed Waiver document will be valid and enforced in the same manner as a hand-signed document that exists in physical form and that a record or signature may not be denied legal effect or enforceability under law solely because it is in electronic form.

Basic Information

Use parent or guardian information if under 18

Contact Information

Use parent or guardian information if under 18

Insurance Information
Minor Information

Enter the information for the children for which you are responsible for:

I, the parent or legal guardian of the student listed above, certify that in case of emergency, and if I cannot be reached by phone, I authorize any chaperone or staff member from The Vine Community Church, to give consent to a physician and/or hospital for emergency medical or surgical treatment while on the trip. It is understood that I will assume any financial responsibility for any expense that may be incurred for said treatment or for transportation home if necessary.

* This form may only be used under the conditions above and in conjunction with the medical release form specific to each trip/event date.

I also certify that this student is covered by adequate accident insurance. My consent and signature are given below. I have read and agreed to the information given on this form.


By entering my name below and clicking the “Submit Waiver” button below, I indicate my acceptance and delivery of this waiver and release. I acknowledge that I have been given an opportunity to prevent or correct any error in connection with this waiver form. If I have submitted this waiver form in error, I will immediately notify you of the error, revoke my signature as instructed, and refrain from participating in any event or activity to which the waiver applies, as provided in Section 204(b) of the Uniform Electronic Transactions Act.