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Country Bible Youth GroupAll-Year
Participation Agreement, Media Permission & MedicalRelease Form
September 2008 to September 2009
Country Bible Church (CBC) welcomes your child’s participation in the Youth MinistryProgram. It is necessary however, for CBC and you to have an understanding regardingCBC’s responsibility and your responsibility in the event of an accident or illnessinvolving any participant in the Youth Ministry Program. We, therefore, ask you to readand agree to the following terms and conditions:
Participation Agreement
I, the parent and/or legal guardian of ____________________________, consent to allow mychild to participate in the youth group conducted by CBC. In consideration of my childbeing allowed to participate in the youth group, I hereby acknowledge and agree asfollows:
1) My child’s participation in the youth group is entirely voluntary.
2) CBC shall not be responsible for any of my child’s personal property that is lost ordamaged by fire, theft, or by other participants.
3) CBC reserves the right to dismiss, temporarily or permanently, any participant whoseconduct isdeemed, by the youth directors, to be detrimental to my child, other participants, staff orany aspect of the youth group.
4) I understand that my child may travel to or from various youth group activities invehicles driven by a driver approved by the directors of the youth ministry.
5) My child has health insurance coverage appropriate for his/her participation in theyouth group. Iunderstand that CBC does not provide any insurance for my child in connection withhis/herparticipation in the youth group.
6) I hereby agree I will not sue or make claims against and I will forever release,indemnify and hold harmless CBC, its employees, agents, successors and assigns,singularly and collectively, from and against any blame and liability for any injury, harm,loss, inconvenience or any other damage of any kind whatsoever, which may result fromor be connected in any way to my child’s participation in youth group activities.
7) I agree that this release covers each and every time my child participates in anyactivity of CBC, whether on premises owned or operated by CBC or at any other location.
Media Permission
Yes, I consent that CBC may use photos or video of my student in church publicationsor on
their weblog or website.
No, Please do not post pictures of my student on CBC’s publications, weblog or website.
Medical Release
____________________________________ ________________________________________________
Parent/Guardian Name (printed) Parent E-mail
_____________________ ________________ ____________ ______________________________
Student Name (printed) Student Birth Date Student Grade Student School
______________________________ ______________________________ ___________________
Home Address City, State, Zip Home Phone
_______________________ ____________________________ ____________________________
Parent Work Phone Parent Cell Phone Other Parent contact
______________________________ ____________________________
Name of emergency contact Emergency Contact Phone
Special Medications or Allergies: _________________________________________________________
______________________________ ______________________________
Family Doctor Name Doctor Phone
______________________________ ___________________ _________________________
Insurance Company Group # Policy #
In the event that my child is injured and I cannot be reached, I grant permission to theadult in charge of my son/daughter to grant permission for emergency medicaltreatment and I agree to be financially responsible for that treatment.I have read and understand the above provisions and it is my intention that by signingbelow I will bind myself, my spouse, the participant, and my and the participant’s heirs,successors, executors, estate and dependents to the terms stated above.
____________________________________ ______________________________
Parent/Guardian Signature Date