Consent/Release Form for Youth Activities for True North Church Name of student/participant * Name of student/participant First Name First Name Last Name Last Name Student/participant’s phone number * Student/Participant’s email * Name of parent(s) or legal guardian(s) * Name of parent(s) or legal guardian(s) First Name First Name Last Name Last Name Parent(s) or legal guardian(s) phone number * Parent(s) or legal guardian(s) email * Street Address * City * State * Zip Code * Emergency Contact (in case we are unable to contact parent(s) or legal guardian(s) * Emergency Contact’s Phone Number * Emergency Contact’s relationship to student/participant * Please list any of the student/participant’s allergies, medical conditions, or behavior issues we should be aware of: * Is True North Church or their representative authorized to approve medical treatment? * Yes No Is the student/participant covered by personal/family medical insurance? * Yes No If yes, please list name of insurer. * If there is no insurer, please fill in with “N/A” Policy or group number * If there is no insurer, please fill in with “N/A” Please read the paragraph below and answer. * Yes, I/We agree No, I/We do not agree I/We acknowledge that participation in activities sponsored by True North Church’s Tribe Youth Group may involve risk to the Participant (and to the Participant’s parents or guardians, if the participant is a minor), and may result in various types in injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in activities sponsored by True North Church’s Tribe Youth Group, the Participant, or parents/guardians if the Participant is a minor, acknowledges and accepts the risks of injury associated with participation in and transportation to and from Tribe Youth Group activities. The participant (or parent/guardian) accepts personal financial responsibility for any injury or loss sustained during the activity or during the transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the Sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “Activity Sponsor”). Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Activity Sponsor for any injury arising directly or indirectly out of the described Activity or transportation to and from the Activity, whether such injury arises out of the negligence of the Activity Sponsor, the Participant, or otherwise. If a dispute over the agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association. Student/Participant’s signature * Parent(s) or legal guardian(s) signature * Today’s Date * Submit If you are human, leave this field blank. Δ