Fillable Discipline, Liability And Medical Release Form printable pdf download

Christ In Youth Discipline, Liability & Medical Release Form

Make a copy for yourself and bring the ORIGINAL to registration

Event you will be attending:

□ SuperStart!

□ Believe

□ MIX

□ Move

□ Engage

□ Wilderness

Please check which one best describes your attendance:

□ Youth/Children’s Minister

□ Sponsor

□ Student

Participant Name ________________________________________________________

Male

Female

Address

City

State

Zip ________

Participant email _________________________ Home Phone _____________ H.S. Graduation Year _________

Church You are Attending with (missions trip n/a) _____________________________________________________

City/State ________________________ Group Leader’s Name (missions trip n/a) __________________________

Health Insurance Company ____________________________________ Policy Number _____________________

Known Allergies and Reactions _______________________Medications Currently Taking ___________________

Parents/Legal Guardians Name (with whom you live) ________________________________________________

Emergency Contact Info of Parent/Legal Guardian:

Cell Phone __________________________ Parent(s) email __________________________________________

Person to notify if parent/legal guardian cannot be reached:

Name ________________________________ Relationship________________________ Phone _______________

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I, the participant or for those under 18 the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to

participate in this Christ In Youth Program. The individual identified on this form understands that all participants are required to abide by the Program

rules and be directly responsible to the Christ In Youth Program Director. The Christ In Youth Program Director assumes responsibility for discipline at

the Program and, if necessary, may, because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full

responsibility for returning the participant home.

Further, I hereby release, forever discharge and agree to hold harmless a) Christ In Youth and its directors, officers, employees, Program Directors,

agents and all other persons or entities acting on their behalf (the “Covered Parties”) and b) the lessor/owner of properties on which the Programs are

held, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature

whatsoever which may be incurred by the participant, the undersigned, and/or any member of the participant’s family by reason of participating in any

activities associated with Christ In Youth Programs whether or not such claims, actions, demands, liability, costs or expenses are caused by the

negligence or omission of any of the Covered Parties. It is my intention to, and I do hereby surrender and waive any rights to sue or exercise any legal

right to seek damages from the Covered Parties from their failure to use reasonable care in any way.

Further, I do authorize the minister or sponsor of the Program, or any Christ In Youth staff member to take the participant to a doctor or hospital and I

hereby authorize medical treatment, including by not limited to emergency surgery or medical treatment, and I hereby assume financial responsibility for

all expenses incurred for such treatment and, if necessary, all expenses to return the participant home.

Further, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of the participation in this Christ In Youth Program.

I hereby release and agree to hold harmless and indemnify the Covered Parties, for any liability and/or expense sustained as the result of negligent,

willful or intentional acts of the participant, including damages to the Program facility and/or keys not returned at the time of group checkout. I agree to

pay for keys not returned at time of group checkout or damage done to any Program facility or Christ In Youth property by the participant.

For valuable consideration received, I hereby irrevocably grant to Christ In Youth, Inc. the worldwide, royalty-free, right to use the participant’s name,

voice, likeness, and image in all forms and media, and in all manners for any lawful purposes, commercial or noncommercial. I understand that my

participation makes me eligible to receive educational information and updates regarding ministry successes and opportunities.

I acknowledge this agreement is intended to be as broad and inclusive as permitted by the laws of the state of Missouri and that if any portion hereof is

held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further agree this agreement will be governed by

and construed in accordance with the laws of the State of Missouri without giving effect to the principles of conflict of law and the courts within Missouri

will be the only courts of competent jurisdiction. I hereby irrevocably submit to the personal jurisdiction of the courts of Jasper County, Missouri.

I hereby certify that I have carefully read the foregoing and acknowledge that I understand and agree to all of the above terms and conditions. I am

aware that by signing this agreement I assume all risks and waive and release certain substantial rights that I may have or possess against Christ In

Youth or any of the covered parties.

Signature of Participant Named Above _____________________________________________________________ ____

(If under 18 parent or legal guardian must sign)

Printed Name of Parent/Legal Guardian _______________________________________ Date ________________ ____

Signature of the Parent/Legal Guardian ____________________________________________________________ ____

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Christ In Youth -- PO Box B -- Joplin, MO 64802 – 417.781.2273 –

Discipline, Liability And Medical Release Form

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