Plymouth Church Liability Waiver and Photo Release
Liability Release and Photo Release for events involved with Plymouth Congregational Church, Paso Robles.
Minor's Name (If you have multiple youth, list all names here).
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Minor's Address
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Parent/ Guardian Name
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Parent/ Guardian Phone Number
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Emergency Contact Name & Relationship to Child
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Emergency Contact Phone Number
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As the undersigned, I agree that: The above named child has my permission to participate in all activities involved in Sunday classes, Date Nights, Youth Overnights, and other events at Plymouth Congregational Church.
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Yes
No
I agree to release Plymouth Congregational Church and its representatives, staff, and volunteers from any claim for personal injury or damages resulting from my child’s participation in the activities associated with Plymouth Congregational Church events.
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Yes
No
I acknowledge that Plymouth Congregational Church and its representatives are not responsible for mine or my child’s personal belongings.
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Yes
No
(For Youth Group Aged): I give permission for transportation of my child in a church or private vehicle in association with Plymouth Congregational Church events.
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Yes
No
Not Applicable
I understand the activities/ events and give my permission for my child’s participation.
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Yes
No
The above named child is covered by medical/ liability insurance.
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Yes
No
As the parent or legal guardian of the above named child, I am authorized to sign this permission form.
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Yes
No
I have read and understand this permission form and understand that Plymouth Congregational Church is released from liability as a result of any injury or damages from my child's participation in activities. I also understand that in the event of emergency or medical need, I have given my permission to have my child receive medical treatment by the best means available.
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Yes
No
Does your child/children have any allergies or medical conditions or special needs that we should know about?
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Yes
No
If you answered "Yes" above, please list the information here:
Does your child/ children require any medication during their time in church care?
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Yes
No
If you answered "Yes" above, please explain here:
NOTE: Church staff and volunteers are prohibited from administering medication to children in the church's care, unless explicitly trained and informed by the parent ahead of time.
If your child uses diapers, do you authorize church staff/volunteers to change their diapers?
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Yes
No
Not Applicable
In consideration for being accepted for participation in the church’s Nursery, Children’s, and/or Youth Ministry program, we (I), being 18 years of age or older, do for ourselves (myself) (and for and on behalf of my minor child participant) do hereby release, forever discharge, and agree to hold harmless the church and its directors from any and 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 that occur while said child is participating in Nursery, Children’s, and/or Youth Ministry programming. Furthermore, we (I) [and on behalf of our (my) child participant] hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreational and work activities involved therein.
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Yes
No
The undersigned further hereby agree to hold harmless and indemnify said organization, its directors, employees, and agents, for any liability sustained by said organization as the result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto. We (I) are the parents(s) or legal guardian(s) of this participant, and hereby grant our (my) permission forhim or her to participate fully in the church’s Nursery, Children’s, and/or Youth Ministry program, and the activities done there, and hereby give our (my) permission to transport or cause to be transported said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.
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Yes
No
Photo Release: I hereby give Plymouth Congregational Church permission to copyright and/or use, reuse and/or publish and/or re-publish photographs, videos, likenesses and images of me and/or my children for the purpose of illustration, advertising media and promoting Plymouth Congregational Church through lawful purposes (e.g. Facebook, Instagram, website, email or printed materials).
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I authorize Plymouth Congregational Church to use photographs or videos of me/ my child(ren).
I DO NOT authorize Plymouth Congregational Church to use photographs or videos of me/ my child(ren).
I have read and understand the above information regarding the photo release.
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Yes
No
Please enter the current date.
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Please sign your name below (By signing this form, you are acknowledging your consent of all the above-listed information).
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Thank you for completing this form!
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