Student First Name
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Student Last Name
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Grade or Group
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K2-K5
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
Career
Other
Parent or Guardian First & Last Name
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Additional Parent or Guardian First & Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Student Cell
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(###)
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Parent or Guardian Cell
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(###)
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Parent or Guardian Work Phone
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Additional Parent or Guardian Cell
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Name
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Phone
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(###)
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Relationship to Student
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Sibling
Aunt or Uncle
Grandparent
Family Friend
Other
Allergies & Health Concerns
Please identify any allergies (including foods), health problems, medications, or other health concerns.
Family Physician
Phone
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Medical/Hospital Insurance Company
Group Number
Policy Holder's Name
Policy Number
Additional Information That May Be Helpful
Legal
DISCLAIMER
First Pentecostal Church and its leaders, directors, officers, employees, contractors, agents, volunteers, members and representatives (collectively referred to as “First Pentecostal Church and/or FPC”), are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, activities or travel with First Pentecostal Church and all related activities associated with the First Pentecostal Church, including injury, loss or damage.
ASSUMPTION OF RISKS
IN CONSIDERATION OF First Pentecostal Church allowing me or my child to participate in events, activities, or travel with FPC and all related activities associated with the FPC, including participation in the Youth Group for the current year inclusive, and all activities related to the Youth Group (collectively referred to as the “Activities”), I acknowledge that I am aware of the possible Risks, Dangers and Hazards associated with participation in the Activities including the possible risk of severe or fatal injury to myself or others.
RELEASE OF LIABILITY and AGREEMENT
IN CONSIDERATION OF First Pentecostal Church allowing me or my child to participate in the Activities, I agree on behalf of myself and/or my child:
1. TO ASSUME and ACCEPT ALL RISKS arising out of, associated with or related to my or my child’s participation in the Activities.
2. TO WAIVE and RELEASE First Pentecostal Church from any and all liability for any loss, damage, injury or expense that I or my child may suffer, or that my next of kin may suffer as a result of my or my child’s participation in the activities due to any cause whatsoever.
3. TO INDEMNIFY and HOLD HARMLESS First Pentecostal Church from any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from my or my child’s participation in the activities.
4. TO INDEMNIFY and HOLD HARMLESS First Pentecostal Church from any and all claims, demands, actions and costs for any loss, injury, damage or expense whatsoever that might arise out of my or my child’s participation in the Activities.
YOUTH PARTICPATION CONSENT
Acknowledgment of Participant:
I, the undersigned Participant, understand that I am responsible to act in a safe and responsible fashion, to follow the instructions or directions of the persons in charge of the Youth Group, and to obey requests to comply with safety regulations as directed by the persons in charge of the Youth Group, including designated leaders and drivers of private or public transportation. I will be solely responsible for myself, will wear a seat-belt when available and will not disturb or distract the driver when using private or public transportation to travel to and from Youth Group activities. At all Youth Group sports events or other activities, I acknowledge that it is my responsibility to obtain and wear appropriate safety equipment. I will not endanger the safety of others or myself at any activities, outings or sports events of the Youth Group or when using private or public transportation for travel to and from such activities. I also understand that I may be photographed or appear in video for such purposes as FPC deems necessary.
Acknowledgment of Parent or Guardian of Participant:
We, the undersigned Parents or Guardians of the Participant, hereby authorize and consent to the Participant’s involvement in the Youth Group, including any use of private or public transportation deemed necessary by the persons in charge of the Youth Group for Participant travel to and from Youth Group activities, or to the NEAREST SUITABLE MEDICAL or HOSPITAL FACILITY in the event that emergency or other medical treatment not available at the site of a Youth Group activity is deemed advisable. We hereby consent to and authorize such emergency or other medical treatment of the Participant as may be deemed advisable in the event of accident, injury, or illness during the activities of the Youth Group.
ACKNOWLEDGEMENT and SIGNATURE
I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT that is binding upon myself and my heirs, executors, administrators, successors and assigns. I HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT and I ACKNOWLEDGE THAT by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that my child or I may have.
This Consent, Authorization and Acknowledgment shall be effective from and including January 1 - December 31, 2023.
Electronic Signature of Student/Participant
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Date Signed
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