Student Ministry Parental Release Form

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Student Information

 
 
 
 
 
Parent/Guardian Information

 
 
 
Emergency Contact

 
 
 
Medical Information

 
 
 
 
Please select one option.
I understand that the Woodland Trace Church of Christ does not provide medical insurance for me. I understand that if I do not have any personal health insurance or accident insurance, that any injury that results from a Ministry Activity will be my sole financial responsibility.
Please select all that apply.
Medical Authorization

I hereby give my consent for any medical treatment, rescue or evacuation services that may be required as determined by staff, medics, emergency personnel, or other professionals during my participation. I, for myself, my heirs, personal representatives, agree to indemnify and hold harmless indemnitees for any cost incurred to treat me. 
Please select all that apply.
Liability Release and Indemnification

I acknowledge that the nature of the Activities or Trips may expose me to hazards or risks that may result in my illness, personal injury or death and I understand and appreciate the nature of such hazards and risks. In consideration of my participation in the Activities or Trips, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release Woodland Trace Church of Christ, its governing board, officers, employees and representatives from any and all liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the Activities or Trips, whether caused by negligence of Woodland Trace Church of Christ, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless Woodland Trace Church of Christ and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligence or intentional act or omission while participating in the described Activities or Trips.

I understand that the Woodland Trace Church of Christ is not responsible for any medical expenses associated with any property or personal injury I may sustain.

I acknowledge and certify by my signature that I am physically fit and able to participate. 
Please select all that apply.
Photographic Release

I hereby authorize the Woodland Trace Church of Christ and those acting in pursuant to its authority to : record my likeness and voice on a video, audio, photographic, digital electronic or any medium; use my name in connection with these recordings; use, reproduce, exhibit, or distribute in any medium (print publications, video tapes, social media, etc.). I release the Woodland Trace Church of Christ and those acting pursuant to its authority from liability for any violation of personal or proprietary right I may have in connection in such use. I understand that all such recording in whatever medium, shall remain the property of the Woodland Trace Church of Christ. 
Please select all that apply.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITIES OR TRIPS AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENCE OR INTENTIONAL ACT OR OMISSION.
Please select all that apply.
 

Description

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