Veronica Springs Church / JOURNEY Participation Form

Student Information

Student's Name

First NameLast Name

Birth Date

MonthDayYear

Age

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Participation Agreement

I hereby give permission for my child to attend and participate in Veronica Springs Church (JOURNEY) events.

Release of Liability

Prior to my child’s involvement in the event activities, I acknowledge that involvement of my child in the event may involve risk of property damage and of personal injury, illness or even death, including but not limited to the risks arising from transportation–related activities, recreational activities, adventure sport activities (surfing, skateboarding, rock climbing, caving, mountain biking, hiking, and canyoneering), accidents in and around facilities, adverse weather conditions, and injuries and illness as a result of food-borne illnesses and allergic reactions.

By signing this Parental Consent and Release of Liability, I state that my child is fully capable of safely participating in all event activities, and I expressly assume all risks of my child’s involvement, whether such risks are known or unknown to me at this time. I further release Veronica Springs Church, its directors, officers, employees, volunteers, and agents, and other participants at the event, from any and all claims that I or my child may have against any of them, whether on or off event grounds. This Release of Liability is given on behalf of myself, my child, and any heirs, family, estate, administrators, and personal representatives of me and my child.

< - - CAUTION - - OUTDOOR RECREATION HAS SERIOUS INHERENT RISKS! PARTICIPATE AT OWN RISK! - - >

I expressly agree that this Release is intended to be as broad and inclusive as permitted by the State of California.

Media Release

I understand that at this event or related activities, my child may be photographed and/or video recorded. I agree to allow my child’s photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and assigns.

Authority to Sign

I have read the above release waiver and by signing it I agree that it is my intention to exempt and relieve Veronica Springs Church from liability for personal injury, property damage or wrongful death. I represent and warrant that I am a parent or legal guardian of the child named above, and have the full power and authority to enter into this Parental Consent and Release of Liability on behalf of the child. By signing below, I acknowledge that I have read and understand this document, and also represent that all information provided is accurate.

I agree that this Release shall be governed by and interpreted in accordance with the laws of the State of California. Any litigation under this agreement shall be resolved in the courts of Santa Barbara County, California.

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment and x-ray examination for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Veronica Springs Church and its affiliates including Pastors, Leaders, and Teachers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the date signed and throughout the duration of the child's involvement in activities with Veronica Springs Church.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Veronica Springs Church (JOURNEY) Participant Agreement