Youth Liability Waiver

Name of Child *

Full legal name of your child is required.

Paren(s) and/or legal guardian(s) of child participant *

Full legal name of parent or guardian is required.

Street Address *

Street address where the child resides.

City *

State *

Zip Code *

Cell Phone *

Other Phone

Age of Child *

Date of Birth *

Academic Grade *

School

Name of the school your child attends.

Health Insurance Company

Insurance Company Name

Policy Number

Insurance Company Phone #

Medical Doctor

Medical Doctor's Phone #

Emergency Contact

Full legal name of emergency contact.

Relationship

Cell Phone

Other Phone

Swimming Ability *

Non-swimmer

Beginner (capable of swimming for several minutes in deep water)

Moderate (capable of swimming several lengths of pool)

Advanced (capable of swimming long distances)

Medical History

Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.):

Other Information

Other information leaders should know about the child or adult participant.

Functions and Activities: *

Yes I agree: It is my understanding that participating in the programs and recreational and other activities of Agape Christian Worship Center is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity related accidents, physical injury due to transportation related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Release of Liability *

Yes I agree: By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me at this time. I further release Agape Christian Worship Center and its leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against Agape Christian Worship Center or its leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless Agape Christian Worship Center and its leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.

First Aid and Emergency Medical Treatment *

Yes I agree: I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of Agape Christian Worship Center to seek and secure any needed medical attention or treatment for the child named above, including hospitalization, if in the agent's opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.

Events and Field Trips *

Yes I agree: I understand that the child named above will be participating in Youth Events during the year of 2018.

Permission for Publicity *

Yes I give permission for publicity

No I do not give permission for publicity

On occasion, Agape Christian Worship Center takes photographs or makes an audio or video recording of children involved in church/youth activities. I consent to the use of any such photos, audio, or video record of the one named above to be used, distributed or displayed as agents of the church see fit.

Participant Consent *

Yes I agree: I represent that I am the parent/guardian of the child listed above who is under 18 years of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of Agape Christian Worship Center, including any special events/activities escribed above. In consideration for allowing the participation of the child in the activities of Agape Christian Worship Center, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

I am 18 or older and I represent myself. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. I hereby consent to the Permission/Waiver Form, including the Release of Liability above, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

By typing my name below, I am electronically signing this liability waiver. *

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Date *

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