Register Your Students Here - Ridge Point Community Church

Ridge Point Community Church
Office Use Only
Family Last Name: _________________
Date Received: ________________
Received by (Dept): _______________
Liability Release and Parent Consent
form for 2015-2016 Ministry Year
Please Return to:
Emily Stafford / Tammy Edgerton
[email protected]
Participant Information:
*If more than 1 child in family, please list all in K-12th
PARTICIPANT NAME
DOB (MM/DD/YY)
Address: ______________________________
GRADE
Grade
Grade
Grade
Grade
Grade
PARENT/GUARDIAN NAME
Best Contact Phone #(s):__________________________
RELEASE OF LIABILITY
The Participant, their parents, guardians, heirs, assigns and representatives hereby release Ridge Point
Community Church, its staff members, volunteers, agents and representatives of any and all liability for any
loss, injury, or property damage which may be the result of any aspect of any church organized event, retreat,
mission trip or excursion the Participant may participate in.
The Participant and the Participant’s Parent(s) and/or Guardian(s) understand, acknowledge and accept that:
• There may be inherent risks, both known and unknown, in travel and in activities the participant will
engage in that may result in an injury, serious injury and/or death.
• Participants are not covered under any policy of insurance held by Ridge Point Community
Church.
• Participants must provide any and all insurance coverage for themselves, including, but not limited to
health, life and liability insurance.
• Photos and videos may be taken of The Participant and may be used in any Ridge Point publications, or
in some cases, partnering organizations affiliated with the event. Publication of these photos and
videos may be done electronically via the internet and that after publication, the church will be unable
to prevent persons from gaining access, copying photos and videos, and subsequently using, altering,
or republishing it without consent.
• Waive any claim for damages against the church from unconsented use, alteration or republication of
photographs or videos that may include The Participant.
PARENTAL CONSENT OF MEDICAL FOR MEDICAL TREATMENT OF MINOR
The Participant and the Participant’s Parent(s) and/or Guardian(s) understand, acknowledge and accept that:
•
They have temporarily entrusted the child to the care of Ridge Point Community Church and its adult staff
members and/or volunteers. If after reasonable attempts to contact the parent(s) or guardian(s) are
unsuccessful, Ridge Point Community Church and the adult staff members or volunteers are authorized by
the parent(s) or guardian(s) to:
o Consent to any x-ray examination, anesthetic, medical and/or surgical diagnosis and/or
treatment, hospital care, and/or dental care for the child which is recommended by a licensed
medical care provider and which will be performed by a licensed medical care provider, licensed
within the state or country where the services are to be performed. Authorization is given to
provide authority and power to designated RPCC adult staff member(s) and/or volunteer(s) to
treat your child when advised by a licensed medical care provider and when the child's parents
are unavailable to give consent.
o Authorize any hospital which has provided treatment to the child to return physical custody of the
child to designated RPCC adult staff member(s) and/or volunteer(s) when treatment is completed.
o
The parent(s) or guardian(s) agree to fully pay for any and all costs of medical or dental care
provided to the minor and consented to by Ridge Point Community Church and/or its adult staff
member(s) and/or volunteer(s).
I have read, understand and accept the terms above. This authorization shall remain in effect until August of
each calendar year, unless revoked in writing by parent or guardian and received by a RPCC staff member.
__________________________________
Dated: __________________________
Parent or Guardian Name & Signature (if participant under age 18)
__________________________________
Dated: __________________________
Parent or Guardian Name & Signature (if participant under age 18)
Medical Information * Please attach additional sheet of information as necessary *
It is the responsibility of the Participant/Parent/Guardian to inform RPCC of changes to this information.
Insurance Information:
Insurance Company: __________________________________________________________________
Policy Number: _____________________________ Plan Number:______________________________
Insurance Co. Address/Phone:___________________________________________________________
Employer Name/Address/Phone:_________________________________________________________
Doctor Information:
Doctor Name: ______________________________Office Name: _______________________________
Office Address/Phone: _____________________________ ____________________________________
Family members under care of this Doctor: _________________________________________________
Doctor Information:
Doctor Name: ______________________________Office Name: _______________________________
Office Address/Phone: _____________________________ ____________________________________
Family members under care of this Doctor: _________________________________________________
Reminder: Emergency Phone, Parent(s)/Guardian(s) Name/Address on top of Page 1.
Child Specific Medical Information:
Child Name:________________________________
DOB: ________________________________
Special Medical Conditions (ex. Allergies, Diabetes, Asthma, etc): _______________________________
____________________________________________________________________________________
Medications currently using & instructions:__________________________________________________
Child Specific Medical Information:
Child Name:________________________________
DOB: ________________________________
Special Medical Conditions (ex. Allergies, Diabetes, Asthma, etc): _______________________________
____________________________________________________________________________________
Medications currently using & instructions:__________________________________________________
Child Specific Medical Information:
Child Name:________________________________
DOB: ________________________________
Special Medical Conditions (ex. Allergies, Diabetes, Asthma, etc): _______________________________
____________________________________________________________________________________
Medications currently using & instructions:__________________________________________________
Child Specific Medical Information:
Child Name:________________________________
DOB: ________________________________
Special Medical Conditions (ex. Allergies, Diabetes, Asthma, etc): _______________________________
____________________________________________________________________________________
Medications currently using & instructions:__________________________________________________
Household Information:
Student Information
Today’s Date:_____________________________________
Parent / Legal Guardian 1:
Student Participant (under 18): First,
First, Middle & Last Name as spelled legally:
Middle & Last Name as spelled legally:
F)________________M)________________L)___________________
F)________________M)________________L)___________________
Address: _________________________________________________
Cell:________________________
City:____________________________State:_____Zip:____________
Gender
Gender:_________
Preferred Email:___________________________________________
Home Phone:____________________Work :____________________
DOB (MM/DD/YY): _________________
School:__________________________________________________
Grade
Grade for the 2015/2016 School Year:________________
Cell:________________________
Gender
Gender:_________
DOB (MM/DD/YY): _________________
Middle & Last Name as spelled legally:
F)________________M)________________L)___________________
Parent / Legal Guardian 2:
Cell:________________________
Gender
Gender:_________
DOB (MM/DD/YY): _________________
First, Middle & Last Name as spelled legally:
School:__________________________________________________
F)________________M)________________L)___________________
Grade
Grade for the 2015/2016 School Year:________________
Address: _________________________________________________
Middle & Last Name as spelled legally:
City:____________________________State:_____Zip:____________
Preferred Email:___________________________________________
F)________________M)________________L)___________________
Home Phone:____________________Work :____________________
Cell:________________________
Cell:________________________
Gender
Gender:_________
Gender
Gender:_________
School:__________________________________________________
DOB (MM/DD/YY): _________________
DOB (MM/DD/YY): _________________
Grade for the 2015/2016 School Year:________________
Grade
EMERGENCY CONTACT INFORMATION:
___________________________________________________
Primary Emergency Contact
Relationship
___________________________________________________
Emergency Phone #’s
Primary Email
___________________________________________________
Secondary Emergency Contact
Relationship
___________________________________________________
Emergency Phone #
Primary Email
Middle & Last Name as spelled legally:
F)________________M)________________L)___________________
Cell:________________________
Gender
Gender:_________
DOB (MM/DD/YY): _________________
School:__________________________________________________
Grade
Grade for the 2015/2016 School Year:________________
Photo/Video Release
(ALL participants)
I hereby authorize and give full consent to Ridge Point Community
Church (RPCC) to publish and copyright all photographs in which I or my
children appear in related to my event experience. Photographs may
by obtained by RPCC team or site leaders or given to RPCC by
participant photographers. I further give my permission to RPCC to use
photos I appear in or have taken and given to RPCC and may transfer,
use or cause to be used, these photographs in brochures, web sites,
newsletters, advertising, posters, displays, slide shows, videotapes,
catalogs, CD-ROMs, social media sites and like publications, literature or
materials without limitations or reservations.
I hereby approve the foregoing and consent to the use of photographs
subject to the terms mentioned above. I affirm that I have the legal
right to issue such consent.
___________________________________________________
Participant Signature (Last 4 Digits of Social)
Date
Parent or Guardian if under 18:
(please specify whether parent or guardian)
Parent
Guardian
___________________________________________________
Participant Signature (Last 4 Digits of Social)
Date
Transport Home Agreement
(ALL participants)
As a participant, parent or guardian, I/We give our consent for
participation on an event being led by Ridge Point Community Church.
I/We understand that the Ridge Point site leader or trip leader of our
group may need to send a participant home as a result of illness or
discipline. I/We understand if a participant is dismissed from the event
site, he/she will be transported home at his/her or parents/guardians
expense. As a participant and parent or legal guardian, I/We accept
these terms. (Ridge Point will attempt to contact the parent or
guardian to arrange such transportation.)
___________________________________________________
Participant Signature (Last 4 Digits of Social)
Date
Parent or Guardian if under 18:
(please specify whether parent or guardian)
Parent
Guardian
___________________________________________________
Signature (Last 4 Digits of Social)
Date
Release of Liability
(ALL participants)
As a Participant, I accept the conditions and risks outlined in this release, as a
participant on a event sponsored by Ridge Point Community Church of Holland,
Michigan. I represent and agree that:
1. As a Participant , I am aware of the potential hazards and risks to the
participant and property associated with participating in an event, such hazards
and risks include, but are not limited to, injury or death by accident, disease,
weather conditions, inadequate medical services and supplies (in remote
locations), criminal activity, and random acts of violence. I accept these risks as a
participant with full awareness of these risks. With respect to Ridge Point
Community Church and its agents, volunteers, officers, directors, and employees,
I assume all known and unknown risks of death, injury, and illness associated
with such risks, and any damage to my personal property, and I release Ridge
Point Community Church and its agents, officers, directors, and employees from
any liability that I may suffer as a result of participation in the mission project.
2. I attest and certify that I have no known medical conditions that would
prevent me from participating.
3. I expressly waive any defense to the enforcement of any provision of this
commitment arising from a claim of lack of consideration and warrant that this
commitment constitutes a legal, valid, and binding obligation upon me
enforceable against me in accordance with its terms.
4. I am aware of the hazards and risks to the participant associated with
participating in an event, as described above. I further understand that Ridge
Point Community Church does not have any insurance coverage that would apply
in the event of the participant’s illness, injury, death, or damage to property that
may occur during participation on the trip, and that if such insurance coverage is
desired, I am responsible for the cost and arrangements for such insurance.
5. I agree to indemnify, defend, and hold harmless Ridge Point Community
Church, its agents, volunteers, officers, directors, and employees from any and
all losses, claims, causes of action, suits, liabilities, and expenses (including, but
not limited to reasonable attorney fees and costs) arising out of or related to the
event as well as any activities prior to or after such event.
5. I expressly agree that this assumption of risk agreement is intended to be as
broad and inclusive as permitted by law. I further state that I HAVE CAREFULLY
READ THE FOREGOING ASSUMPTION OF RISK AND UNDERSTAND ITS CONTENTS,
AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT. THIS IS A LEGAL
DOCUMENT AND I UNDERSTAND THAT I HAVE THE OPPORTUNITY TO CONSULT
WITH AN ATTORNEY BEFORE SIGNING IT.
6. Every provision of this Agreement is intended to be severable. If any term,
provision, section or subsection of this Agreement is declared to be illegal or
invalid, for any reason whatsoever, by a court of competent jurisdiction, such
illegality or invalidity shall not affect the other terms, provisions, sections or
subsections of this Agreement, which shall remain binding and enforceable.
I have read, understand and accept the terms above.
Parent Signature (Last 4 Digits of Social: ___________ Date:________
Parent Name:_________________________________________