CLPC Kids and Student Ministry Permission Form

Clear Lake Presbyterian Church Kids and Student Ministry Permission Form - 2025
Name of sponsoring organization: Clear Lake Presbyterian Church

Address: 1511 El Dorado Blvd., Houston, TX 77062

Phone: 281-488-6731

This permission form is valid from January 1, 2025 through December 31, 2025.
PARTICIPANT INFORMATION
Name of Participant*

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name of Emergency Contact if Parent/Guardian cannot be reached*

First NameLast Name
Phone of Emergency Contact*
Please enter a valid phone number.Format: (000) 000-0000.
List Allergies or Medical Conditions:
Any other information we should know regarding your child?
Permission to Participate in Program Activities
I acknowledge that participation in Clear Lake Presbyterian activities involves risk to the participant (and to the participant's parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activity described above (the "activity"), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the "activity sponsor"). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless that activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association. *

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Authorization of Consent for Treatment of Minors
I, as the person having the power to consent to medical treatment of the above minor, authorize leaders of Clear Lake Presbyterian Church to consent to medical treatment of such minor when I cannot be contacted to so consent, which includes, without limitation, medical transport, x-ray examination, anesthetic, medical, dental, or surgical examination or treatment, and general hospital care. No prior determination or life-threatening emergency or danger of serious or permanent injury resulting from delay of treatment need be made under this authorization. I will indemnify and hold harmless from any expenses or claims of any nature and entity which provides or causes to be provided examination, treatment, or hospital care pursuant to this authorization (except to the extent such entity is negligent therein) and conditionally agree to make cause or otherwise, full and complete payment for such examination, treatment, or hospital care.*

Clear
Permission to be Photographed or Filmed
YesNo
Permission to be Photographed or Filmed Signature

Clear
Should be Empty:

Clear Lake Presbyterian Church Kids and Student Ministry Permission Form - 2025

PARTICIPANT INFORMATION

Permission to Participate in Program Activities

Authorization of Consent for Treatment of Minors

Permission to be Photographed or Filmed