I, the lawful parent or guardian of
____THE CHILD/REN INCLUDED ON THIS DIGITAL FORM _____
(“Child”), give permission for my Child to participate in all activities hosted by the Christ Centered Community Church (“C4”) Family Ministry.
2. I release from all liability and indemnify C4’s directors, officers, council members, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any damage, injury or illness incurred or caused by my Child while participating in or traveling to or from the activity, or otherwise in C4 Family Ministry’s custody. I understand the risks in these activities, including the possibility of unforeseen hazards, serious injury, or death. I certify my Child is able to participate in the activity.
3. I agree to instruct my Child to cooperate with C4’s Family Ministry and its representatives in charge of the activity and understand my Child may be prohibited from participating and/or sent home for any failure to follow the rules established by C4’s Family Ministry.
4. I appoint C4 Family Ministry representatives who are acting as leaders, or designated by such leaders, as my attorney in fact to act for me in my name and my behalf, in any way that I could act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity, related travel or while my Child is in C4 Family Ministry’s custody.
a. To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency transportation, medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our medical attorney-in-fact shall deem necessary or appropriate for the best interest of the Child.
b. I understand C4 Family Ministry’s will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my Child.
5. My Child is to be excluded from the following activities
______LIST BELOW___________________
and/or from release to the following persons
______LIST BELOW___________________
(IF LEFT BLANK (N/A) , NO ACTIVITIES OR PERSONS ARE EXCLUDED.)
6. I agree that C4 Family Ministry may use my Child’s and/or my own name, voice, portrait, photograph or image for promotional, website, office, or any other C4 or C4 Family Ministry related purposes. These may be used in any broadcast, telecast, digital or print medium, including video images, photographs, pictures or renderings, audio recordings, or other likenesses, in combination or alone.
By checking this box, I agree that I am the Parent / Legal Guardian of the Child/ Children included in this form, & I agree to the above waiver of liability.
