2022 E.L.E.C.T. Teen Summit

Student Name *

Prefix First Name Last Name

Parent Name *

Prefix First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Phone *

Area Code Phone Number

Cell Number *

Area Code Phone Number

Child's Number *

Area Code Phone Number

E-mail *

Does your child have any allergies or medical conditions we should be aware of? This includes food allergies, medicine, asthma, behavioral, etc. This information will be confidential. This is to help us be aware.

Yes No

CCDN will end the 2022 E.L.E.C.T. Teen Summit with a fun day across the street from the church. All parents are required to sign a liability waiver for their child to participate in the fun day. IF weather permits the fun day will be moved inside. Do you want your child to participate?

Yes No

I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in all activities conducted by Community Care Development

I understand

Yes No

TRANSPORTATION RELEASE

Applies to students only I give permission for my youth to be transported to and from, Community Care Development Network sponsored activities in a church, rental, or private vehicle. I understand that parents are responsible for picking students up from the main facility by the designated pick up time.

I understand

Yes No

DISCIPLINE RELEASE

Applies to students only In the event of misconduct, I authorize the staff to send my student home at my expense.

I understand

Yes No

INSURANCE RELEASE

Applies to all traveling I realize the Community Care Development Network’s insurance begins where the individual health and accident policy terminates. It is only valid when all other insurance has been extended to its limits.

I understand

Yes No

PERSONAL BELONGINGS RELEASE

Applies to all traveling I realize that the Community Care Development Network or its sponsors are not responsible for personal belongings.

I understand

Yes No

Photography Release

I grant to [insert organization], its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Community Care Development Network its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Community Care Development Network may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as news, publicity, illustration, advertising, Social Media, and Web content.

I understand

Yes No

GENERAL RELEASE

Applies to all traveling The undersigned or a member of the immediate family of the undersigned realizes that the participant may incur personal injury or bodily damage while participating in such activities, and acknowledge that the Community Care Development Network, it’s officers, directors, employees, agents, or any other parties volunteering on behalf of the organization, shall be held harmless from all actions, claims, costs, expenses or damages of any kind, growing out of or related to any activities of the church. The undersigned or a member of the immediate family of the undersigned further acknowledge this is a full and complete release for all injuries and damages which the participant may sustain as a result of participating in any activity. I, am the legal guardian of the child mentioned in this application and give my permission for him/her to participate in CCDN sponsored activities.

I understand

Yes No

Community Care Development Network Hold Harmless Agreement and Waiver Release of Liability

Each individual participant (or authorized guardian, if minor) must read and sign this release of liability prior to participating in Community Care Development Network Community Outreach Programs. This includes volunteer opportunities, events, and E.L.E.C.T. Teen Summit.

To participate in activities, I, the undersigned, agree and acknowledge that there is a risk of injury from these activities and/or from the equipment involved. I freely assume all such risks, both known and unknown, and assume full responsibility for my participation and safety.

I have read and understand the rules, including all safety-related rules, and agree to fully comply with all rules and regulations during my participation. I, for myself, and on behalf of my heirs, assigns, personal representatives, and next of kin hereby release and hold harmless Community Care Development Network, their officers, officials, agents, employees, or vendors, from any and all liability for injury, disability, death, loss or damage to personal property.

Safety Rules and Guidelines

Participants are to respond to instructions, rules, and safety guidelines always.
Participants are not to run, jump, or horseplay in an indoor environment.
Participants are to refrain from horseplay in all outreach activities
Participants are to display good behavior, character, and judgment always

I, agree to indemnify and hold harmless Community Care Development Network against any and all claims, suits, or actions of any kind whatsoever for liability, damages, compensation, or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.

If Community Care Development Network incurs any of these types of expenses, I agree to reimburse Community Care Development Network. I, agree if I am a business or entity (church, school, library, restaurant, etc.) that it is my responsibility to monitor all parties while anyone is participating in outreach activities and events

I acknowledge, understand, and agree that I have read this release of liability and assume all risk associated with participating and that I sign this release of liability voluntarily and without inducement. I, the undersigned participant, affirm that I am of the age of 18 years or older and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content, and that this release cannot be modified orally.

Minor Age Participants (under age 18) All participants under the age of 18 at the time of the event must have a parent or guardian sign below. (Entities must sign) I hereby certify that I am the parent or guardian with legal responsibility for the above-signed participant and agree to his/her participation and release and hold harmless Community Care Development Network, their officers, officials, agents, employees, or vendors from any and all liability for his/her injury, disability, death, loss or damage to personal property. I acknowledge that I have read this release of liability in its entirety and assume all risk for the above-named minor and sign this release voluntarily and without inducement.

I understand

Yes No

Signature

Clear

2022 E.L.E.C.T. Teen Summit Registration Form