Humble Walk Youth Group 2026-2027
Participant Waiver
Youth Name:
First Name
Last Name
Youth Contact Email:
example@example.com
Youth Phone Number (If applicable):
Are text reminders/updates sent to the youth/family ok?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth Grade Level:
Youth Birthdate (so we can send a birthday greeting!)
Parent/Guardian 1:
Parent/Guardian 1 Phone:
Parent/Guardian 1 Email:
Parent/Guardian 2 (if applicable):
Parent/Guardian 2 Phone:
Parent/Guardian 2 Email:
Youth Food Allergies/Dietary Needs:
Special needs, activity restrictions or concerns the staff should be aware of (ex: participant is allergic to bees and will be carrying an EpiPen):
Additional Emergency Contact Name:
Emergency Contact Phone:
Relationship to Participant:
Who is authorized to pick up your child?
Do we have permission to post your child's photo or video on social media, with other youth group families in a photo highlight reel and in print publications?
Yes
No
Group Photos/Videos Only
I hereby authorize my child to participate in Humble Walk Lutheran Church Youth Group Activities. I further authorize the making and use of any pictures, films or other recordings of these activities for any purpose, that Humble Walk Church may make or authorize to be made without compensation to my child or me. Furthermore, I agree that all activities and use of all facilities relating to participation in Humble Walk Youth Group activities shall be undertaken at the sole risk of the participant/family and that Humble Walk Lutheran Church, its representatives, agents, employees, leaders, and participants in its programs shall not be liable for any claims, demands, injuries, damage, actions or causes of action, whatsoever, to me, my family, or my property arising out of or connected with participation in these programs/events or the premises where the programs/events occur and I do hereby expressly forever release, discharge, and hold harmless Humble Walk Lutheran Church, its representatives, agents, employees, leaders, and participants in its programs from all such claims, demands, injuries, damage to person or property, actions or causes of action. I do not, however, release these individuals and entities from liability for intentional, willful or wanton acts and this release shall not be construed to include such acts. I have read and understand and agree to the terms and conditions of this release. I understand that I have given up rights by signing this release and sign it freely and without inducement. If an injury develops during an activity or event, medical care will be provided and I will be notified as soon as possible. I understand that it is my responsibility to provide updates (including changes in health conditions and medical coverage) prior to the event. I understand and accept the above statements and further authorize each of the following: The health history and medical information I have provided is correct and the above-named participant has my permission to engage in all program activities as noted. If an injury or other medical condition occurs or arises, I grant permission for medical treatment to be obtained for the participant and authorize the physician and/or the other medical staff to employ such diagnostic procedures and medical treatment as deemed necessary. I authorize the release of any medical records necessary for treatment, referral, billing, or insurance purposes.I understand that I am financially responsible for charges and hereby guarantee full payment to the attending physicians and/or health unit.
Submit
Should be Empty: