King's Table Participation Form

This form MUST be filled out and signed by a Legal Guardian.

Participants Name

Age

Gender

Cognitive Age

Which of the following best describes the participant

Living Arrangement

Address

Phone

Group Home Information, if applicable

Group Home Name

Group Home Phone

Group Home Manager Name

Group Home Manager Phone

Group Home Manager Email

Other information

Type of disabilities

Allergies

Triggers

Restrictions

Likes/Comforts

Is the participant on any offender registries? (This may or may not exclude from programming)

Yes No

Is there any other information of which we should be aware?

Emergency Contact Information

Name

Relationship

Phone

Legal Guardian

I am my own guardian

Yes No

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

This address will receive a confirmation email

Permissions

I acknowledge that I have voluntarily agreed to participate in The King's Table Ministries activities and/or events.

Permission to Participate

Yes No

I hereby authorize The King’s Table Ministries to publish photographs or videos taken of us, the above mentioned participants and our names and likenesses, for use in The King’s Table Ministries print, online and video-based marketing materials, as well as other ministry publications.

Photo/Video Release Consent

Yes No

As consideration for being permitted by The King’s Table Ministries to participate in activities and events, I forever release The King’s Table Ministries and its respective directors, officers, volunteers, and agents (collectively “Releasees”) from any and all actions, claims, or demands that I, my assignees, heirs, distributees, guardians, next of kin, spouse and legal representatives now have, or may have in the future, for injury or property damage, related to (i) my participation in these activities, (ii) the negligence or other acts, whether directly connected to these activities or not, and however caused, by any Releasees, or (iii) the condition of the premises where these activities occur, whether or not I am then participating in the activities. I also agree that I, my assignees, heirs, distributees, guardians, next of kin, spouse, and legal representatives will not make a claim against, sue, or attach the property of any Releasees in connection with any of the matters covered by the foregoing release.

Liability Release

Yes No

Legal Guardian must sign this form before his/her ward may attend.

Electronic Signature:

Date:

King's Table Participation Form

Description

Please Fix the Following