THRIVE CHURCH Permission and Liability Release YouthQuake/Trinity Worship Center, Burlington NC 9/25-9/26/2015 Activity/Event: _________________________________________________________ Date(s):_________________________ Student: _____________________________________________________
Youth Cell Phone__________________________
Address: ______________________________________________________ City/State/Zip___________________________ Date of birth: ____________________________Youth Email: ___________________________________________________ Parent or Custodial Adult Name:____________________________________Work Phone: ___________________________ Mobile phone: _________________________________
Email: ________________________________________________
Parent or Custodial Adult Name ___________________________________ Work Phone: ___________________________ Mobile phone: __________________________________
Email: ________________________________________________
Consent and Release of Liability I, the undersigned, being the parent or legal guardian of the student named above, do hereby consent to his/her participation in the aforementioned event with Thrive Church. I acknowledge that there are certain risks associated with off-campus activities, including but not limited to, physical injury, illness or even death. I expressly warrant that the student named above, or I, if I am a participant, is capable of withstanding both the physical and mental demands of the activity or event. I expressly assume all risks associated with participation in the activity or event, whether such risks are known or unknown to me at this time. I further release the church and its pastors, leaders, employees, volunteers and agents from any claim that I, my child, family members, estate or heirs may have against them as a result of injury or illness incurred during the course of participation in these activities. I agree to notify the youth leader in writing of any health changes that would restrict the student’s participation in any activities. I understand the youth leader and designated adult chaperones reserve the right to restrict participation in any activity that they do not feel is within the physical capabilities of the student. Medical Treatment Authorization I hereby authorize Thrive Church and/or its representatives to make emergency medical care decisions on behalf of me, if I am the participant, or my child to include providing consent for any x-ray examinations, anesthesia or other treatment as deemed necessary by a medical provider. I understand that Thrive Church will not be responsible for medical expenses and I agree to pay all fees and costs arising from necessary medical treatment and actions to obtain said medical treatment. Medical Information Current Medical Condition(s) ________________________________________________________________________
Current Medication(s)________________________________________ Dosage/Frequency___________________________ Side Effects of Medication(s)_____________________________________________________________________________ Allergies (including allergies to medications)________________________________________________________________ Describe Symptoms/Reaction____________________________________________________________________________ Does your child carry an ___ Epi-Pen ____Inhailer Special Needs or Limitations _____________________________________________________________________________ Physician’s Name _________________________________________________Phone # ______________________________ *Please attach a copy of your current insurance card. All medications should be given to the youth leader and must be labeled with the student’s name, dosage and frequency.
Transportation Permission I authorize Thrive Church and/or its representatives to transport my child to and from the event or activity. I agree to hold harmless, Thrive Church, it’s agents and assigns, in the event of any accident resulting in harm, injury or damage to my child or me, if I am a participant. Restrictions if any should be listed below: (i.e. my son/daughter may not ride in a vehicle without adult supervision; my son/daughter should remain in a group accompanied by an adult.) ____________________________________________________________________________________________ I give permission for my youth to be photographed and understand photos will be used at the discretion of Thrive Church and it’s agents. _____________________________________________ Participant (over age 18)/Parent/Guardian Signature
___________________________ Date
Code of Conduct The Code of Conduct is to help each of us enjoy the Christian fellowship of activities sponsored by Thrive Church. We are here to love and learn about Jesus Christ. We will conduct ourselves in a “manner worthy of the gospel” (Philippians 1:27). 1. Listen and learn from leadership; both youth and adults. 2. Encourage and build one another up. Bullying, teasing, or disrespect to students or adults will not be tolerated. 3. Clean up after yourself. 4. No tobacco, illegal drugs, non-prescribed medication, alcohol or other drugs. 5. No weapons of any kind. 6. No profane or offensive language. 7. Cell phones and personal listening devices must be turned off during meetings and activities, unless otherwise directed by the youth leader. 8. No inappropriate displays of affection such as kissing, prolonged embracing or other inappropriate physical contact. 9. No inappropriate clothing: shorts/skirts should be of appropriate length, no low cut tops or spaghetti straps. Boys must keep shirts on at all times, unless during a swimming event. Swimsuits must be one-piece or tankini. A dark colored t-shirt must be worn over a two-piece. 10. Students will stay with the group unless permission is granted from the youth leader. Students may not come and go during activities. 11. Confidentiality and trust are important to developing a safe environment. Information shared during group conversations will not be shared outside the group. Youth Pledge I hereby pledge to uphold the Youth Code of Conduct during all youth activities. I agree to follow all instructions of the youth leader and/or adult chaperones. I understand that failure to abide by the code of conduct may result in disciplinary action to include being sent home, at my parent’s expense, or being refused participation in future events and/or activities. In some cases, there may be additional rules implemented by the event sponsor. In such situations, the rules will be provided prior to registration of said event. ____________________________________________ Student Signature
____________________________ Date
WAIVER AND RELEASE OF LIABILITY In consideration of Splatbrothers Paintball / Air Soft ®furnishing services and/or equipment to enable me to participate in Paintball / Air Soft games, I agree as follows: I fully understand and acknowledge that; (a) risks and dangers exist in my use of Paintball / Air Soft equipment and my participation in Paintball / Air Soft activities; (b) my participation in such activities and/or use of such equipment may result in my injury or illness including but not limited to bodily injury, disease, strains, fractures, partial and or total paralysis, eye injury, blindness, heat stroke, heart attack, death or other ailments that could cause serious disability; (c) these risks and dangers may be caused by negligence of the owners, employees, officers or agents of Splatbrothers Paintball the negligence of the participants, the negligence of others, accidents, breaches of contract, the forces of nature or other causes. These risks and dangers may arise from foreseeable or unforeseeable causes; and (d) by my participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages, whether caused in whole or in part by the negligence or other conduct of the owners, officers, members, agents, employees, special promoters, or suppliers of Splatbrothers Paintball. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify Splatbrothers Paintball / Air Soft ®, and it's owners, agents, officers and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of Paintball / Air Soft equipment or my participation in Paintball / Air Soft activities, I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers, members, employees, special promoters or suppliers of Splatbrothers Paintball / Air Soft ®. I agree to be responsible for loss, theft, or damages to any Splatbrothers Paintball or Splatbrothers Air soft ™ equipment. In consideration for value received, receipt whereof is acknowledged, I hereby give Splatbrothers Paintball / Air Soft ®, and their photographers the absolute right and permission to publish, copyright and use pictures (including moving pictures) of me in which I may be included in whole or in part, composite or retouched in character or form: If the person photographed is under 18, I certify that I am his or her parent or legal guardian and I give my consent without reservation to the foregoing on his or her behalf. In consideration for value received, receipt whereof is acknowledged, I hereby give Splatbrothers Paintball / Air Soft ®, a nonexclusive license to any and all photographic, film, or video images captured, taken, or developed from the Splatbrothers Paintball Park and to the use by Splatbrothers Paintball / Air Soft ®, of the images without limitation. I understand and agree that Splatbrothers Paintball / Air Soft ®, is not responsible for the loss or theft of personal property.
I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE IT IS MY INTENTION TO EXEMPT AND RELIEVE SPLATBROTHERS PAINTBALL / AIRSOFT ®, SPLATBROTHERS PAINTBALL STAFF, VOLUNTEERS, SUPPLIERS, SPECIAL PROMOTERS, LANDOWNERS OR ANY OTHER SUCH PERSON FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE. THIS WAIVER EXPIRES 2/28/16 AT 11:59 PM.
_____________________________________________ Signature of player if 18 years of age Print Player Name:________________________________ Age______ Birth date: __________ Today’s Date : __________ Address City State Zip Code: ____________________________________________________________________________ Email Address: _______________________________________________________________________________________ MINORS (information below for players under 18 years of age): Emergency contact person for player under 18 years of age: _____________________________________________________ Emergency Contact Phone Number for player under 18 years of age: ______________________________________________ Parent/Guardian Signature (If participant is less then 18 years old.) _______________________________________________
