Youth Release Form General

Last Name

First Name

Nickname

Birth Date

Date

Grade for following Fall:

Youth Email

example@example.com

Youth Primary Phone (If they have one)

Please enter a valid phone number.Format: (000) 000-0000.

Allergies

Shirt Size

Parent Name #1

Relation

Parent Name #2

Relation

Parents Primary Email

example@example.com

Parents Primary Phone

Please enter a valid phone number.Format: (000) 000-0000.

Insurance Company

Policy Number

Secondary emails or phone numbers

Extra Email

example@example.com

Extra Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

As a participant of St. Paul's Episcopal Church, I understand that I represent myself, the church, and God. Acknowledging this, I will do my best to fulfill the mission of St. Paul's Youth

"To create a community where youth feel comfortable being who God made them to be without worry of judgement or prejudice but rather acceptance and love."

Youth Signature

I herby consent to the collection and use of my/my child's images by photography or video recording. I also consent to the participation in interviews and the use of quotes. I acknowledge that they may be used on St. Paul's websites, blogs, newsletters and publications; social network mediums; by media (both print and broadcast), as well as in distribution to mailing list members. I also grant St. Paul's Episcopal Church the right to edit, use and reuse said products. Ialso hereby release St. Paul's Episcopal, its agents and employees from all claims, demands and liabilities whatsoever in connection with the aforementioned.

Parent Signature

Date

St. Paul's Youth Liability Release Form

I, hereby grant release to St. Paul's Episcopal Church in Winston Salem, NC and the directors thereof from any an all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant while participating in any trip or activity, other than as liability may be subject to indemnity under available insurance covering St. Paul's Episcopal Church of Winston Salem, NC and/or its directors and/or agents.

Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.

The undersigned further herby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

If the participant has not attained the age of 21 years: We (I) are the parents(s) or legal guardian(s) of this participant, and hereby grant our (my) permission from him/her to participate fully, and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the primary responsibility of all medical bills, if any.

ParentGuardian Signature

Date

ParentGuardian Signature

Date