2023 Youth Waiver

a form must be filled out for each youth (persons 17 and younger) to be renewed each year

Parent / Guardian Name

First Name

Last Name

Email

Mobile Number

(###)

###

####

Child / Youth Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Mobile Number

(###)

###

####

AB Health Care #

Medical

List any medical conditions, allergies, medications, etc. pertinent to the child.

Parental Consent

Please read the LCC parental consent terms below

YES

NO

LCC Parental Consent

LIABILITY RELEASE: In consideration of Langdon Community Church allowing the Participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Langdon Community Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and child care, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician/dentist or the medical staff of a licensed hospital/dental or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by said Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

PROMOTION PERMISSION: I agree that Langdon Community Church may photograph and record my child/youth image during church-related activities. I grant the following rights to said Church: permission to use and re-use, publish and re-publish, and modify or alter the images and video taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the internet, and worldwide in perpetuity for the purposes stated above. I waive my right to inspect or approve any editorial text or copy that is used in connection with the images and release and discharge said Church from any and all claims arising out of use of the images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.