Waiver and Release Form

Waiver and Release Form

This form is to be completed by parents/guardians/responsible party of each participant age 17 and under. For group registrations, only one form is required.
Responsible Party Name

First NameLast Name
Participant Information
Participant/Responsible Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant/Responsible Party Phone Number
Format: (000) 000-0000.
Participant Grade Level
Participant Age
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Format: (000) 000-0000.
Waiver and Release

Please read carefully.
I hereby grant my child permission to participate in Summer Summit 2026. I acknowledge that there are inherent risks associated with this event, and I assume full responsibility for those risks.

I understand that travel may be involved. I hereby give permission for my child to travel with the adult leader or leaders of this event, including transportation by car, bus, train, airplane, or other means.

I understand it may be necessary for emergency medical treatment to be administered if an injury or illness occurs during the Summer Summit. In an emergency, I consent to medical treatment provided by a doctor or hospital of the church's choice.

I grant permission to an adult leader of this event, my appointed agent if needed, to provide consent for any medical diagnosis or treatment, including x-ray examinations, dental services, surgery, and hospital care advised by a licensed physician, surgeon, or dentist in the state where these services are rendered. This may include visits to a doctor's office as well as hospitals.

I acknowledge that photography, audio, and video recording may occur during Summer Summit 2026. These images and recordings may be used for promotional, educational, or documentation purposes by the Second Episcopal District of the African Methodist Episcopal Church in various media, including but not limited to websites, social media, printed materials, and presentations. I consent to the capturing and use of my child’s image, voice, and likeness as described above. I consent to releasing the Second Episcopal District employees or agents from any liability that may arise from these materials.

I understand it is incumbent upon me and/or my child to follow all rules set by the church concerning this event. I further acknowledge that any misconduct or misbehavior on the part of my child or myself may result in immediate dismissal from the event, at the sole discretion of the church staff.

I also agree to release and hold the church and its staff harmless from all liability related to injury or illness that may occur to my child during this event or any associated activity.
Parent/Guardian Signature
Statement of Agreement
Today's Date

MonthDayYear
Date
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