YFC 2015 - Fireproof Permission Slip

3830 N. 67th Avenue
Phoenix, AZ 85033
Phone: 623-849-2363
PERMISSION SLIP/HEALTH FORM, LIABILITY RELEASE
Activity: Youth For Christ (YFC) Summer Camp
Where: 27224 Hwy 78, Ramona, California, 92065
When: July 26 - August 1
STUDENT INFORMATION
Student Name _________________________________________________________ Phone _________________________________
Grade ______________________ Date of Birth _______/_______/_______
Address _______________________________________ City ____________________ State __________ Zip Code ________________
Parent or Legal Guardian _______________________________________________________ Relationship ______________________
Phone ________________________________ Email _________________________________________________________________
Emergency Contact ______________________________________________________ Phone ________________________________
Emergency Contact ______________________________________________________ Phone ________________________________
INSURANCE AND MEDICAL INFORMATION
Do you have medical insurance? Yes ____ No ____
If yes, please complete the following:
Your Insurance Carrier _______________________ Policy Number/Group Number ___________________________
If no, I acknowledge that I do not have medical insurance and relinquish CATALYST CHURCH from any liability.
Signature ______________________________________________________________________
Date_________________________
If your child has any medical conditions/ medication/ food allergies that we need to know about, please list
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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PARENTAL CONSENT
Waiver and release
In consideration of my child’s participation in the activities of CATALYST CHURCH , I ______________________________,
hereby, for myself, my heirs, executors, administrators and assigns, release, waive and/or forever discharge any and all
rights and claims for damages that may be suffered by my child as a result of his/her preparation for, participation in or
traveling to or from the activities. I recognize the risks associated with my child’s participation in the activities and
specifically agree to indemnify and hold harmless CATALYST CHURCH, including any members of the governing body
and any Promoter, sponsors, or subcontractors whose facilities and/or services are being used for these activities, from
any and all injuries or damages arising from or in any way contributed to the subject of this forms participation in these
activities. Parents must approve the waiver for their children under the age of 18 years.
I, the parent, guardian or legal custodian of the above named participant do hereby assent to the above waiver and
release and agree to all terms as stated above.
Initial _____________
I, who by law may do so, authorize the administration of emergency medical treatment to he/she who is the Subject of
this form. I understand all reasonable safety precautions will be taken at all times by CATALYST CHURCH or its agents for
any accident, injury or disease incurred by the subject of this form. I understand that in the event medical intervention is
needed every attempt will be made to contact the person(s) below immediately.
Initial _____________
Photograph Release
I hereby authorize CATALYST CHURCH to take photos and to publish photographs taken of
_________________________ (student) during the Fireproof outing. Photos may be used to promote Fireproof through
CATALYST CHURCH media,
I hereby release and hold harmless CATALYST CHURCH from any reasonable expectation of privacy or confidentiality
associated with the images specified above.
I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type
associated with the talking or publication of these photographs or participation In CATALYST CHURCH materials. I
acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.
I hereby release CATALYST CHURCH, its employees, and any third parties involved in the creation or publication of
materials, form liability for any claims by me or any third party in connection with participation.
Printed Name _________________________________________________
Signature _____________________________________________________
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Date ______________________