OK- theres alot i know- but basically you need to copy and paste eveything thats here onto a word document, print and get parents to sign in all the right places- any questions just give me a call :)

 

 

Spokane Caption Challenge
Friday, May 16th 2008

Barbeque at Mission Park
Friday, May 23rd, 2008

Name of Child or Adult Participant (please print) ____________________________________________
Parent(s) and/or legal guardian(s) of child participant ____________________________________________
Address ________________________________________________________________________________
Street City State Zip
Home Phone (______) _______________________ Work Phone (______) ___________________________
Age of Child ___________________ Birth Date ____________________ MALE FEMALE
Academic Grade ______________ School ________________________________________________

 

Functions and Activities
It is my understanding that participating in the programs and recreational and other activities of The Salvation Army is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents or illness. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

 

Release of Liability
By signing this Permission/Waiver Form, I expressly warrant that the child named above or I (if I am a participant) am capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release The Salvation Army and its staff, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against The Salvation Army or its staff, volunteers, or agents.
I further agree to indemnify and hold harmless The Salvation Army and its staff volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.



Special Events and Field Trips
I understand that the child named above or I will be participating in:

A Caption competition (children taking photos at various sites around spokane) on Friday, May 16th

A Barbeque at Mission Park, Friday May 23rd.

This is a time to share in fellowship w/ other youth group members and leaders. I understand that during this period my child/ward or I, if I am an adult participant, may take part in activities such as:
-A car/van ride to/from the activity
-(For caption competition) Visiting various sites around spokane and taking pictures with leaders and other participants

-(For BBQ) all activities associated with a barbeque (games etc)

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of The Salvation Army to seek and secure any needed medical attention or treatment for the child named above or me, if I am a participant, including hospitalization if in the agent’s opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment.
I give permission for attending physician(s), dentist and other medical personnel to administer any needed medical treatment, including surgery and anesthesia and, again; I agree to pay for the medical treatment.
Publicity

On occasion, The Salvation Army takes photographs or makes an audio or videotape recording of children and/or adults involved in unit activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in The Salvation Army publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events; and The Salvation Army may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the child named above or me, if I am participating, to be used, distributed, or displayed as agents of the Salvation Army see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media or for such photographs and other audio or visual records to be used by the news media.


Please sign stating you have received the Notice of Privacy Practices (HIPPA):

signature




Medical History
Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.):







Health Insurance Information
Insurance Company: _______________________________________________
Policy Number: ___________________________________________________
Phone Number: ___________________________________________________
Medical Doctor: ___________________________________________________

Emergency Contacts
Names of persons and telephone numbers to call in case of emergency:

_________________________________ _______________________ _____________________
Parent/Guardian Home Phone Work Phone
_________________________________ _______________________ _____________________
Parent/Guardian Home Phone Work Phone
_________________________________ _______________________ _____________________
Other Home Phone Work Phone
Other Information
Other information leaders should know about the child or adult participant:






• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
For Use Only if the Participant is a Minor
I represent that I am the parent/guardian of _________________________, who is under 18 years of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof.
I give permission for the child named above to participate in the activities of The Salvation Army, including any special events/activities described above. In consideration for allowing the participation of the child in the activities of The Salvation Army, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

____________________________________________________________ ______________________
Signature of Parent or Legal Guardian Date

____________________________________________________________
Print Name of Parent or Legal Guardian

____________________________________________________________ ______________________
Witness Signature Date

Adult Volunteers and Employees
As an adult volunteer or unit employee, I hereby agree to each of the consents and waivers listed above, including the Release of Liability, as pertaining to my own participation in functions, activities, special events, and field trips.

____________________________________________________________ _______________________
Signature Date
Add your content here