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General Release Form – Minor
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General Release Form – Minor
General Release Form – Minor
Becky Boyland
2016-12-27T21:00:11-06:00
Participant's Name
*
First
Last
Number of Additional Participants
----- None -----
1
2
3
4
2nd Participant's Name
First
Last
Please leave blank if only signing for one child.
3rd Participant's Name
First
Last
Please leave blank if only signing for one child.
4th Participant's Name
First
Last
Please leave blank if only signing for one child.
5th Participant's Name
First
Last
Please leave blank if only signing for one child.
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*
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*
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*
First
Last
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*
Activity
*
Date(s) of Activity
*
I am the parent or legal guardian of the above minor who desires to participate in the various programs, events or activities listed above, (hereinafter collectively referred to as the “Activities”) operated or sponsored by Heartland Community Church of Rockford, Inc. (the ”Church”).
I understand and acknowledge that the Church will not allow the minor to participate in the Activities without releasing and holding the Church harmless from any liability arising out of participation in the Activities. I have investigated the risks involved in the Minor’s participation in the Activities and fully understand and assume such risks on my behalf. Specifically, I understand and acknowledge that the Minor may suffer or experience, among other things, personal injury or bodily damage, medical disabilities, loss or theft of personal property, abduction and even death.
I REQUEST THAT THE CHURCH ALLOW THE MINOR TO PARTICIPATE IN THE ACTIVITIES, AND IN CONSIDERATION THEREOF AGREE HEREBY TO RELEASE AND FOREVER DISCHARGE THE CHURCH, ITS OFFICERS AND DIRECTORS, AND ITS EMPLOYEES, AGENTS, AND ANY PERSONS VOLUNTEERING ON BEHALF OF THE CHURCH, FROM ALL ACTIONS, CAUSES OF ACTION, INJURIES, CLAIMS, DAMAGES, COST OR EXPENSES OF ANY KIND, GROWING OUT OF OR RELATED TO ANY SUCH ACTIVITIES IN WHICH THE MINOR PARTICIPATES. I UNDERSTAND THAT THIS IS A FULL AND COMPLETE RELEASE OF ALL INJURIES AND DAMAGES WHICH I OR THE MINOR MAY SUSTAIN AS A RESULT OF HIS/HER PARTICIPATION IN ANY OF THE ACTIVITIES, REGARDLESS OF THE SPECIFIC CAUSE THEREOF.
I acknowledge and agree that I have given my consent for the minor to remain in the custody of the Church’s representatives while participating in the Activities. This Agreement is binding on the minor’s heirs, successors and personal representatives.
Initial
*
In the event the minor suffers any injury or condition during his or her participation in the Activities, including transportation to and from the Activities, which may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me and my spouse have been unsuccessful, I hereby appoint the attending Heartland staff member or agent as my agent to act for me and in my name (in any way I could act in person) to make any and all decisions for the minor concerning his or her personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate when the agent is first able to contact me or my spouse.
Initial
*
Regarding photographs of myself or my child(ren) taken at the Activities, I give Heartland Community Church permission to do the following for non-profit use and without charge: use at the discretion of Heartland, display at a service or event or be used in a multimedia presentation, reprint and distribute for any Heartland non-profit publication with copyright to accompany photo when used, display on the Heartland website, or use quotes and video clips on the Heartland website and blog.
The undersigned agrees to the above Initialed sections and this agreement is binding on my Heirs, Successors and personal Representatives.
Parent or Legal Guardian
*
First
Last
Initial
*
Date
*
Second Parent or Legal Guardian
First
Last
Initial
Date
* View the
photography and video release form
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