Activity Participation Permission Form

Richland AC Church Liability Release Form

As of January 2022, parents are required to fill out this form for every child who attends Children’s Ministry or Youth Ministry events when the parent will be dropping off their children. Once this form has been filled out, it does not need to be filled out again, unless your information has changed.

Child Name *

First

Last

Child's Birthday *

Child Gender *

Child's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian #1 Information

Please fill out the following information for the parent/guardian.

Parent/Guardian #1's Name *

First

Last

Parent/Guardian #1's Cell Phone *

Parent/Guardian #1's Email *

Confirm Email

Parent/Guardian #2 Information

Please fill out the following information for the parent/guardian #2 (if applicable).

Parent/Guardian #2 Name

First

Last

Parent/Guardian #2's Cell Phone

Parent/Guardian #2's Email

Confirm Email

Emergency Contact

Please fill out the information below for an emergency contact other than the parent(s)/guardian(s).

Emergency Contact's Name *

First

Last

Emergency Contact's Relationship to Child *

Child's medical information in case of emergency:

Please list any allergies the child has: *

Please list any medications the child is regularly taking: *

Please list any special instructions for the child: *

In case of an emergency and Richland AC Church cannot reach me by phone, I give consent for my child to be taken to the closest hospital. I give consent by typing my name below: *

Name of Child's Primary Physician *

First

Last

Child's Primary Physician Phone *

Trusted People for Pick Up *

Please list people besides parents who are authorized to pick up your child from Richland AC Church Events. Please include a contact number. We will ask to see identification from anyone picking up the child.

Rules of Behavior

The overseeing Event Leader/Coordinator is responsible for maintaining such behavior in the group, and has authority to direct offenders to be picked up by their parent/guardian.

Behavior that is not tolerated includes, but may not be limited to:

1. Fighting, harassment, continued coarse speech or behavior
2. Possession of any weapon or dangerous object
3. Possession of tobacco, alcohol, or controlled substances
4. Males are not allowed in female bathrooms and females are not allowed in male bathrooms at anytime.
5. No one is to stray from the group location. In the event that someone becomes separated by accident, they must make every effort to immediately rejoin the group
6. Respect for and compliance for event/facility rules
7. Safe and moral conduct is mandatory for every participant at every event.

I agree to the Rules of Behavior *

Medical Consent

As the Parent/Legal Guardian of (child listed above), I authorize Richland Apostolic Church, into whose care the minor has been entrusted, to consent to medical or dental treatment and/or care under [insert Washington Code here]. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, and is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment may deem advisable.

I give my consent *

Parent and Child Release Statement

As parent/legal guardian of (child listed above) I have reviewed the information about Children/Youth Ministry activity/event and give my permission for the subject of this release to be involved in the overall activities listed above. I acknowledge that my child’s participation in Richland Apostolic Christian Church's Children and or Youth Ministry is voluntary and may require involvement in events that require traveling or physical exertion. I acknowledge that his/her participation in any Richland Apostolic Christian Church Children/Youth Ministry event presents risks that my child may suffer property damage, bodily injury, or death.

Parental/Guardian Acknowledgement

I/we have reviewed the rules of the activity and agree that the subject of this release will abide by them.

I/we also acknowledge that if the subject of this release has to return home early for any discipline violations it will be at my/our expense.

I/we consent to the use of any video images, photographs, audio recordings or any visual or audio reproduction that may be taken of the subject of this release during the activity/event to be used, distributed or shown as Richland Apostolic Christian Church deems appropriate.

I/we understand all reasonable safety precautions will be taken at all times by Richland Apostolic Christian Church and its agents during the events and activities.

I/we understand the possibilities of unforeseen hazards and know the inherent possibility of risk.

I/we agree to hold harmless Richland Apostolic Christian Church, its leaders, employees and volunteer staff for damages losses, diseases or injuries incurred by the subject of this release.

My child has permission to attend all church sponsored Children/Youth Ministry events.

NOTE: If you desire to limit your participation in any event, please put your restrictions to King’s Harbor Church in writing in advance of the event.

The undersigned has read and voluntarily signed this release and waiver of liability and indemnity agreement, and further agrees that no oral representation, statements or inducement apart from the foregoing written agreement have been made.

By typing my name below, I give my consent to all of the above *