"RELEASE, WAIVER, AND INDEMNITY AGREEMENT"
RELEASE, WAIVER, AND INDEMNITY AGREEMENT YOUTH ACTIVITIES AT TRINITY UMC 2012-2013 It is the intention of ________________________________________ (Parent or guardian of minor) by this agreement to exempt and relieve Trinity United Methodist Church and its officers, agents, servants, or employees from liability for personal injury, property damage, or wrongful death of ___________________________________ (Name of minor) caused by any act of negligence of Trinity United Methodist Church and its officers, agents, servants, or employees. For and in consideration of permitting said minor to observe, or use any facility or equipment of Trinity United Methodist Church, 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 Trinity United Methodist Church 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 of above named minor 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 Trinity United Methodist Church or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless Trinity United Methodist Church and its officers, agents, servants, or employees from any and all claims or causes of action by above named minor or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of above named minor present any claim against Trinity United Methodist Church and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by Trinity United Methodist Church and said persons. The undersigned parent or guardian represent 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. ____________________________________________ Dated: ________________ Signature of parent or guardian For _____________________________________ (Name of minor) Medical Information form Trinity UMC 2012-2013 Parent/Guardian Names: _______________________________________________________________ Home number: __________________________ Work Number: _________________________ Cell Number: _________________________ Emergency Contact (name, relationship and phone number other than parents’ cell phone number) _____________________________________________________________________________________ _____________________________________________________________________________________ Please list any pertinent medical information below, including medications being taken and known allergies: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ A photocopy of your child’s insurance card MUST accompany this form. It will not be considered complete without it. ***In case of emergency, hospitals will not bill your insurance without a copy of the card. I understand that conduct problems will be dealt with accordingly, and if severe enough parents will be responsible for picking their youth up. ______________________________________________ ___________________ Parent Signature Date ______________________________________________ ___________________ Parent E-mail Address Phone Number I will participate in all activities as planned for this trip/event, and will follow the rules as set forth by adult and youth leaders. ______________________________________________ ___________________ Youth Signature Date Trinity UMC Photograph, video, and audio material permission form 2012-2013 I, the undersigned, hereby consent to the use of any videotapes, photographs, slides, audiotapes/CDs or any other visual or audio reproduction in which I may appear by Trinity United Methodist Church. I understand that these materials are being used for promotion of the youth ministry of Trinity United Methodist Church, which includes recruitment and fund raising efforts. I release Trinity United Methodist Church from any liability connected with the use of my picture or voice recording as part of any promotional, recruitment or fund raising program. Student Signature _____________________________ Date______________ Parent/Guardian Signature ______________________ Date______________