Release of Liability For by M3wWABC3


									Release of Liability Form

574 Rimer Pond Road, Blythewood, SC 29016

General Release
         By participating in the activities of VillageChurch, I acknowledge that there may
be inherent or other risks involved. I agree to release VillageChurch and its agents from
all liability of damage and injury to myself or to the participant indicated below for
whom I am the Parent/Legal guardian.

Transportation Release
       I/We the undersigned do hereby give permission to VillageChurch and its agents
and representatives to transport the participant named below to and from any
program, ministry, or activity sponsored by VillageChurch and I/We hereby release
VillageChurch, its agents and representatives from any and all liability that may
otherwise attach during the course of transporting the below named person to or
from a program, ministry or activity.

        I, the undersigned, have read and understand the above agreement and release
from liability through December 31, 2012.

Participant’s Full Name (Please Print)
Participant’s Address

City _____________________________ State ______________ Zip Code
Home Phone Number ________________________________
Emergency Phone Number ____________________________

Participant’s Signature __________________________________
Date ___________________
Parent/Guardian’s Signature ____________________________
Date ___________________
If a minor, signature of parent or guardian Permission Form
My name is (parent/guardian)                                         , and by this instrument I do
hereby release, acquit, hold harmless and forever discharge VillageChurch, its agents, servants and
employees and all persons, natural or corporate, in privity with them or any of them, from any and
all claims or causes of action of any kind whatsoever, including but not limited to actions, suits
and/or claims for any bodily injuries, death or property damage which may be sustained by
___________ (student name) while participating with my permission at Getaway 2011,
including travel to and from such activities, not resulting from the intentional tortuous act or acts
of any agent, servant or employee of VillageChurch. It is acknowledged that the decision to engage
in the above activities is entered into freely, and that VillageChurch, its agents, servants and
employees have not influenced the decision to engage in such activities. I also understand that
VillageChurch is a Christian organization and that my child may be exposed to Christian principles
and Biblical activities. I also give my permission for my child to receive medical treatment in case
of an emergency.

Parent Signature:
Community Covenant
Because of the potential dangers regarding a trip, I understand the need to be
responsible on this trip and follow these specific guidelines. I realize my actions may
affect the safety and the community of this trip.
   1) I understand that I need to abstain from public (or private) displays of affection if I am not married.
   2) I understand and I will honor the established music/electronics guidelines (ipods, mp3 players,
       etc.). Cell phones are not allowed during Getaway functions, but may be brought to Gatlinburg and
       used at specified times. If caught using one of these devices outside of the regulated time will result
       in the leadership collecting your device, which you will not get back.
   3) I understand the need for separated sleeping arrangements, and will honor this. I will not set foot
       on the doorstep of the housing quarters of the opposite sex without an adult or permission from an
       adult and by no means will I set foot in any bedrooms or unauthorized areas during mealtime.
   4) I understand that I cannot be outside of my room after “lights out.”
   5) I understand that I’m not allowed to POSSESS or USE tobacco, alcohol, or any other type of drugs.
   6) I understand that I’m not allowed to POSSESS or USE any weapon or fireworks.
   7) I understand that I’m not allowed to haze, harass, threaten, or intimidate another student.
Consequences for breaking guideline #
  1-2 These actions will be confronted once. Students who disobey will result in losing ownership
      privileges of their device and will have to work during free time.
  3-7 These actions will result in being sent home at your family’s expense.

I will follow the above guidelines and respect the VillageChurch leadership. I understand the
consequences if I choose not to follow the rules.

____________________________                          ____________________________
Student Signature                                          Print Name

I understand all of the guidelines and safety procedures and the potential consequences. If my
son/daughter chooses to not honor guidelines 3-7, I realize that he/she will be sent home at my
expense. I have discussed these guidelines with my student, and am confident he/she will honor
these guidelines and the VillageChurch leadership.

____________________________                          ____________________________
Parent Signature                                           Print Name

To top