House 1:14 Registration & Liability Form '24-'25

House 1:14

Participant Registration & Liability Waiver '24-'25 School Year
Participant Information:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade ('24-25 school year)*
Student Phone Number (optional)
Please enter a valid phone number.
Student Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information:
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
E-mail*
example@example.com
Emergency Contact
Name*

First NameLast Name
Emergency Contact Phone Number*

Participant Acknowledgements

The participant must read and affirm the following statements.
I understand that any House 1:14 staff or volunteer may ask me to leave the property if my actions are deemed, at their discretion, disrespectful or inconsistent with House 1:14 conduct expectations. I understand that if I am asked to leave the property, I must do so.
I understand that if I am asked to leave the property, my parent/guardian will be notified by a House 1:14 board member, staff, or volunteer.
I understand that House 1:14, its staff, board members, and volunteers, are not responsible for accidents at House 1:14.
I understand that House 1:14 staff and volunteers have the right to search my personal property & possessions at House 1:14.
I understand that House 1:14 has an active security camera system, and that I am being filmed while in the house.
I understand that House 1:14 staff or volunteers have the right to confiscate any item (including electronics) while I am in the house, at their discretion. I understand my property will be returned to me upon my departure of the House.

Terms and Conditions of Participation
1. RELEASE OF LIABILITY

I understand participating in House 114 activities is a privilege. In consideration of this privilege, I release House 114, including its directors, volunteers, employees, sponsors & agents from liability of any physical injury, including death or illness, while participating at a House 114.

I understand that my child may participate in any number of activities. I understand there are certain risks associated with any activity; I will assume responsibility for these risks, whether known or unknown to me at this time. This release includes all claims of my family, estate, heirs, personal representative or assigns.

If I am under 18, my parent / guardian, by signing below, consents to my release & he or she agrees that this release shall be binding upon him or her as my parent / guardian as to me & my estate, heirs, personal representatives & assigns. My parent / guardian also promises to defend, indemnify & hold House 114 harmless from any claim asserted by me against House 114, including its directors, volunteers, employees, sponsors & agents, if I should repudiate this release after obtaining adulthood.

For the consideration stated above, I further agree that in the event that my child or I should make any claim against the above-named program, activity, or sport, I will personally indemnify, defend & hold harmless the organization & its agents, employees, representatives, successors & assigns against any accidental physical or other personal injury, loss of personal property, illness or death caused by infectious and/or contagious diseases or sickness while at House 114. I will not hold House 114 responsible for any lost, stolen or damaged property, including attorney’s fees.

2. BEHAVIORAL AGREEMENT

I understand that illegal or immoral activities or behavioral issues may result in the named participant being sent home at the expense of the parents / guardians. I also agree to the code of conduct established by House 114. These activities include but are not limited to: possession or use of drugs, alcohol or weapons; sex; stealing; fighting; etc. House 114 will make every effort to contact the parents / guardians to make arrangements before the named participant is sent home.

3. MEDICAL INFORMATION

Any medication brought to House 114 must be accompanied by written instructions from a physician / parent. All prescriptions must be brought in the original container in which they were issued (with medical instructions, dosage information, etc.).

4. MEDIA RELEASE

I hereby grant permission to House 114 to use, reproduce & / or distribute any photographs, film, video recordings & audio recordings of me / my child without compensation or approval rights for use in materials created for the purposes of promoting future activities and the child’s safety at House 114.

5. MEDICAL TREATMENT AUTHORIZATION

In case of an emergency, I understand that efforts will be made to contact me. However, if I cannot be reached, I hereby give House 114 & its representative’s permission to act on my behalf in seeking emergency medical treatment for my child in the event that such treatment is deemed necessary or advisable for my child’s health, safety & welfare. I give permission to those administering medical treatment to do so, using the measures deemed necessary. I release House 114, its representatives & all medical providers from liability in acting in this regard & rendering such medical treatment. I will be fully responsible for all such medical expenses.
My signature below indicates that I have read & understand the above information & accept all the conditions contained therein. By signing this form, I release House 1:14, its staff, representatives, sponsors, agents, or volunteers, of any liability.
Signature of Participant

Clear
Date signed*

MonthDayYear
Date
Signature of Parent/guardian

Clear
Date signed*

MonthDayYear
Date
Should be Empty:

House 1:14

Participant Information:

Parent/Guardian Information:

Emergency Contact

Participant Acknowledgements

Terms and Conditions of Participation