Parent/Guardian Name
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Parent/Guardian Address
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Parent/Guardian Phone Number
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Parent/Guardian Email Address
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Number of Children Attending
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Names and Ages/Grades of Children
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Medical Concerns/Allergies
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Please list any special medical concerns/allergies which may potentially affect your child on this particular church activity. Any required medications are the responsibility of the child. The church and its personnel are not allowed to dispense any medications without specific parental permission. *If your child has no medical concerns/allergies, please write N/A.*
Authorized Pick-Up
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Please list those who may pick up your children at the end of the AWAWA night. This list can be amended only by the registering parent/guardian. *If there are no other individuals authorized to pick-up your child, please write N/A.*
How should we contact you for schedule changes?
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RELEASE, WAIVER, AND INDEMNITY AGREEMENT
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IT IS THE INTENTION OF THE UNDERSIGNED PARENT OR GUARDIAN BY THIS AGREEMENT TO EXEMPT AND RELIEVE LAKE LANSING BAPTIST CHURCH (HEREAFTER REFERRED TO AS LLBC) AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF THEIR CHILD CAUSED BY ANY ACT OF NEGLIGENCE OF LLBC AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES. For and in consideration of permitting their child to observe, or use any facility or equipment of LLBC, or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at LLBC, the undersigned parent and/or guardian hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to their child as a result of their observing or using facilities or equipment of LLBC, or engaging in or receiving instructions in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. The undersigned parent or guardian for him/herself, his/her heirs, executors, administrators, or assigns, agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against LLBC or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless LLBC and its officers, agents, servants, or employees from any and all claims or causes of action by their child or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian present any claim against LLBC and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by LLBC and said persons. The undersigned parent or guardian represents that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
PHOTO AND MEDIA RELEASE
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I, the legal parent/guardian of the aforementioned minor child/children, hereby authorize and consent to the use of images or videos of my child/children listed above, with or without their name(s), by LLBC for purposes including but not limited to: promotional materials, printed publications, internet posts including social media, television, and other media sources. I do this with full knowledge and consent and waive all claims for compensation for use or for damages. I release LLBC, its officers, trustees, employees, and agents from liability for any claims by me or any third party in connection with the use of the image of my child/children listed above.
