Youth Parental Consent and Liability Release Form

This form needs to be filled out for every student who attends Newport Church Youth Events.

Your name *

Email address *

Student's First Name *

Student's Last Name *

Student's Nickname

Birthdate *

(MM/DD/YYYY)

Grade *

Address *

Parent(s)/Guardian(s) and Other Contacts

Parent/Guardian Name *

Parent/Guardian Email *

2nd Parent/Guardian Email *

Phone number *

Work Number

Parent/Guardian Cell Phone *

2nd Parent/Guardian Cell Phone

Non - Parent Emergency Contact #1 *

Emergency Contact 1 Primary Relationship *

Emergency Contact Primary Phone *

Non - Parent Emergency Contact #2 *

Emergency Contact #2 Primary Relationship *

Emergency Contact 2 Primary Phone *

Medical/Health/Insurance Care Information

Student's Doctor's Name *

Address

Phone number *

Medications (type N/A if none) *

Allergies (type N/A if no know allergies) *

Immunizations *

Special Conditions *

Schedule & Instructions Rules and Habits

Meals

Snacks

Other

AMATEUR WAIVER AND RELEASE OF LIABILITY READ BEFORE SIGNING

In consideration of being allowed to participate in any way in NEWPORT CHURCH YOUTH MINISTRY, related events and activities, the undersigned acknowledges, appreciates, and agrees that:

1) INJURY RISK *

As the parent or legal guardian, I hereby give permission for my child to participate in the Newport Church Youth Ministry. I understand that Newport Church is a nonprofit charitable institution, which is voluntarily presenting this program for my child, other participants, and the community. I also understand that the program has activities that can involve physical contact with other participants, the ground or equipment, and that there is a resulting risk of physical injury to my child. I have explained these risks and benefits of participating in this program to my child and my child is in proper physical condition and has no existing injuries or conditions that could jeopardize his/her safety or health, or the safety or health of the other participants. I therefore release and discharge all liability for any harm or injury suffered directly or indirectly as a result of my child's participation in Newport Church Youth Ministry Events, whether or not resulting from negligence, and I agree not to sue Newport Church, its representatives, staff, or volunteers on any such claim. I also give permission for the staff, representative, or volunteers of Newport Church to administer first aid or to seek medical care for my child during my child's participation in the program, including transportation of my child to a medical facility for additional treatment that appears necessary.

2) Photo Release *

I hereby grant Newport Church permission to use my likeness and my child's likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.
I understand and agree that all photos will become the property of Newport Church and will not be returned.
I hereby irrevocably authorize Newport Church to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.
I hereby hold harmless, release, and forever discharge Newport Church from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I HAVE READ AND UNDERSTAND THE ABOVE PHIOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OFAGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/ GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:

Yes

3) Confirm Reading of Release *

I have read this Release of Liability and Assumption of Risk Agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.

4) Agreement | Guardian Must Sign *

By applying my electronic signature to this agreement, I agree that my electronic signature is the legally binding equivalent of my handwritten signature on paper. I will not, at any future time, claim that my electronic signature is not legally binding or enforceable. By electronically signing and submitting this agreement, I 1) acknowledge that I have read and fully understand the terms of the agreement; 2) voluntarily agree to be bound by this agreement; and 3) certify that I am 18 years of age or older. My signature applies to all pages of this contract. I understand that I will receive a Portable Document Format (PDF) version of this agreement after it is signed at the email address I have provided. To view the PDF document, I understand that I will need software that enables me to receive and access PDF files such as Adobe Reader software or other software capable of reading a PDF file. In order to print and retain a hard copy of this agreement, I understand that I will also need a printer connected to my computer. I understand that if I wish to sign a hard copy of this agreement instead of an electronic version, I must contact the party that requires my signature on this agreement directly. A parent or legal guardian must sign this agreement on behalf of any minor participant under the age of 18. By electronically signing this agreement, I represent that I have the authority to sign and enter into this agreement on behalf of the minor(s) listed above.

Electronic Signature: PRINT NAME BELOW to electronically sign release *

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