2024 Empowered to Conquer Permission Form

Empowered to Conquer Limitless Retreat Permission Form

I am a parent or legal guardian of hereby give permission for him/her to receive transportation from school on Friday, Feb 9th by Empowered to Conquer (ETC) for the overnight Limitless Retreat held Feb. 9th-11th, 2024. I understand my child will be picked up from school on Friday and return to the school on Sunday Feb. 11th. I will be responsible for picking them up at the designated time. I also permit my child to participate in outings with my consent with mentors from the program.

Please provide the following information of the emergency contact for the student.

Student Name*

First NameLast Name

Name of Parent of Legal Guardian*

Address*

Telephone (Day)*

(Evening)

Email*

example@example.com

Parent/Guardian Name*

First NameLast Name

I hold harmless from liability any person transporting him/her to or from any activity. I hereby waive, indemnify, forfeit, and forever release ETC and its volunteers, staff, successors and/or assigns from any liability from and against

all losses, claims, liabilities, causes of action, or responsibilities of any nature or kind whatsoever, whether personal or professional arising out of his/her involvement and participation in any way. I agree for him/her to be a part of photographers or videos taken during LimitlessRetreat activities.

If any part of this waiver is declared unenforceable or invalid, the remainder will continue to be valid and enforceable. I have carefully read and foregoing release and indemnification and understanding the contents thereof sign this release as my own free act.

Please any allergies the student presently has or medication he/she must take during while in our care:

Medication and Allergies and requirements:*

Name [Student]*

Signature [parent/legal guardian*

Date*

Date