I, * acknowledge that participation of my child, * in the Cornerstone of Lakewood Ranch youth program (the “Cornerstone Youth Program”) is voluntary and may require involvement in activities that require traveling or physical exertion. Such activities may include, but are not limited to: outings, retreats, athletic events, competitions, contests, games, local excursions and meetings. I acknowledge that my Child’s participation in any youth activity during the Cornerstone Youth Program presents risks that my child may suffer property damage, bodily injury or death, and I acknowledge that I have been fully informed of such risks. Therefore, in order for my child to be allowed to participate in the Cornerstone Youth Program, I agree to the following:
I hereby fully assume the risks of my child participating in all Cornerstone activities, including but not limited to the risk of property damage, personal injury, bodily harm, illness, or death of my child and I take the following actions on behalf of my child, myself, child co-parent, my spouse and/or domestic partner, my executors, administrators, heirs, next of kin, successors and assigns: A) I waive, release and forever discharge and hold harmless Cornerstone of Lakewood Ranch, its Pastors, Elders, officers, directors, employees, volunteers, representatives, subcontractors, successors assigns, and agents of any of the above (collectively, “Releasees”), of and from any and all liabilities, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from child participation in the Program; B) I agree not to sue or bring any legal action or proceeding against any of the Releasees for any claim, liability, injury or damage whatsoever, except in the case of intentional misconduct by any of the Releasees; and: C) I agree to indemnify, defend, and hold harmless the Releasees from any claims, liabilities, injuries, judgments, damages, and costs, including attorney’s fees, assessed against any of them as a result of my child actions in connection with the Cornerstone Youth Program or as a result of any injuries or damages sustained by my child in connection with the Cornerstone Youth Program.
I authorize any designated representative of the Cornerstone Youth Program activities in which my child is participating to secure emergency medical treatment as deemed necessary by that designated leader, including, but not limited to: examination, X-ray, hospital care, hospitalization, injections, anesthesia, surgery and any other emergency medical or dental diagnosis or treatment for my child. I also authorize any licensed physician, emergency, medical technician, hospital or other medical or health care facility to render emergency medical care to my minor child for the purpose of attempting to treat or relieve any injury, illness or other medical problem sustained by my child. I understand that any medical bills that may be incurred will be my responsibility. I consent to the administration of anesthesia as deemed advisable by the emergency medical provider who is rendering care to my child. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical or dental treatment, and I assume any such risk for and on behalf of myself and said child. I understand that attempts will be made to contact me in the most expeditious manner possible. Permission is also granted to Cornerstone of Lakewood Ranch representative(s) to provide the needed first aid or emergency medical care to my child prior to the arrival of trained emergency medical personnel or his or her admission to a medical facility. I, on behalf of my child, myself, child co-parent, my spouse and/or domestic partner, my executors, administrators, heirs, next of kin, successors, and assigns, do hereby release and forever discharge Releasees from any claim whatsoever which arises or may hereafter arise on account of any first aid, medical treatment, or any other service rendered in connection with child participation in the Cornerstone Youth Program.
I hereby authorize and give permission for my child to ride in any vehicle used by Cornerstone Youth Program for transportation of program participants. Should it be necessary for my child to return home due to medical reasons, I shall assume all transportation costs. I also acknowledge and agree that any misconduct on the part of my child may also result in he or she being transported home early from an activity at my expense and inconvenience. A student dismissed for a disciplinary reason will not receive a refund of the activity fee.
I agree that Cornerstone of Lakewood Ranch is not responsible for the loss or theft of my child personal belongings.
I understand this form is required for all overnight trips sponsored by Cornerstone of Lakewood Ranch. I agree to update this form on an annual basis from date of originally signed, or on an as-needed basis (i.e. if meds or allergies change).
VIDEO & PHOTO RELEASE
I agree that Cornerstone of Lakewood Ranch, PCA may photograph and record my child/dependent’s likeness and activities (Images)[1] during church-related activities. I grant the following rights to Cornerstone of Lakewood Ranch: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.
I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge Cornerstone of Lakewood Ranch from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortious act.
I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.
[1] Image means all photographs, film, or other recordings taken of you as part of the Shoot.