hereby grant permission for him/her to participate

Transcription

1 2018 Middle School Leader Legacy - Southview Baptist Release (June 17-21, 2018) As parent/guardian(s) we (I) are informed of the travel, planned activities, and focus of the 2018 Leader Legacy. With this information, we are confident that every measure will be taken to protect the safety of all participants. So on behalf of said student we (I) hereby release, forever discharge, and agree to hold harmless, Southview Baptist Church (SBC), Cincinnati Christian University (CCU), the Creation Museum, the Ark Encounter, Answers in Genesis, the Christian Thinkers Society, and the representatives thereof, from any and all liability, claims or demands for 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 that occur while said child is participating in the 2018 Leader Legacy. Furthermore, we (I) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and activities involved therein. We (I) are the parent(s) or legal guardian(s) of this participant and hereby grant permission for him/her to participate and hereby give SBC representatives permission to take him/her to a doctor or hospital and authorize necessary medical treatment (Shane Lakey, Kelly Parsons, Phil Dean, Ronald Tate, Elizabeth Cole, Rob Parsons, Matthew Ferri, Rebecca Lakey, Heather Chatham, Max Meadows, Patricia Dehaan). We (I) will assume all responsibility for all medical bills, if any are incurred. I understand that if medical treatment is required I will be contacted as soon as possible. Should it be necessary for my child to be sent home for medical reasons, disciplinary reasons, or otherwise, we (I) hereby assume all related costs. Regarding photography and videos: Pictures and videos documenting our trip will be taken. It is our general policy not to post student ministry owned pictures or videos online (church website, student ministry facebook groups) without parent/guardian consent. As parent/guardian, please check the box below that represents your desire: Yes, Southview may use the image of my student in photo or video form posted to the church website, student ministry facebook groups, or church newsletter. No, I don t mind a slideshow shown at church, but please do not post images of my student online. Student Name (print): Parent Name (print): Parent Signature: Date:

2 ARK ENCOUNTER OVERNIGHT STAY Permission, Liability Release and Medical Authorization Form Ark Encounter Overnight Stay DATE CHILD S NAME AGE PARENT/GUARDIAN NAME ADDRESS CITY STATE ZIP PHONE ( ) ALTERNATE EMERGENCY PHONE ( ) Consent to attend I hereby authorize (my child or ward) to participate in an overnight stay and in all activities involved with the stay at the Ark Encounter on, 20. I hereby release, and agree to indemnify and hold harmless, Ark Encounter, LLC, Crosswater Canyon, Inc., and Answers in Genesis, Inc., and all their respective directors, officers, managers, owners, employees, volunteers, agents and representatives (collectively, the Released Parties ) from and against any and all liabilities, loss, or damage to persons or property which may occur in connection with the overnight stay program at the Ark Encounter (the program ), to the fullest extent permitted by law. I agree to assume all risks associated with my child s participation in the program. Parent/ Guardian Signature Date Permission to render emergency medical care I, the (father, mother, guardian) of (child s name), the minor participating in the overnight stay, hereby authorize public safety personnel of Answers in Genesis, Crosswater Canyon, and Ark Encounter, and their other assigned safety personnel, employees, volunteers, agents, and representatives to render emergency medical care to my child within their scope of training, and to act on my behalf to consent to any medical, hospital or emergency care or treatment deemed to be necessary or advisable for the child upon the advice of any licensed physicians, dentists, nurses, or emergency medical personnel. I also give consent for my child to be transported to an emergency medical care center if the need arises. I agree to be responsible for all necessary charges incurred by any transportation, hospitalization or treatment rendered pursuant to this authorization. I agree to indemnify and hold harmless the Released Parties from any and all liability in connection with such medical treatment. Parent/ Guardian Signature Date

3 Medical Information Family Physician s name Business Phone ( ) CHILD S MEDICAL HISTORY Is child in good health? List Allergies: Date of last tetanus shot: List any physical impairments (such as Heart, Epilepsy, Diabetes, etc.): Specify any medication that must be administered: Other special instructions Health Insurance company name: Policy Number Telephone

4 CREATION MUSEUM OVERNIGHT STAY Permission, Liability Release and Medical Authorization Form Creation Museum Overnight Stay DATE CHILD S NAME AGE PARENT/GUARDIAN NAME ADDRESS CITY STATE ZIP PHONE ( ) ALTERNATE EMERGENCY PHONE ( ) Consent to attend I hereby authorize (my child or ward) to participate in an overnight stay and in all activities involved with the stay at the Answers in Genesis Creation Museum on, 20. I hereby release, and agree to indemnify and hold harmless, Answers in Genesis, and all directors, officers, employees, agents and representatives of Answers in Genesis from and against any and all liabilities, loss, or damage to persons or property which may occur in connection with the program, to the fullest extent permitted by law. I agree to assume all risks associated with my child s participation in the program. Parent/ Guardian Signature Date Permission to render emergency medical care I, the (father, mother, guardian) of (child s name), the minor participating in the overnight stay, hereby authorize Answers in Genesis public safety personnel, and other employees, volunteers, agents, and representatives of Answers in Genesis to render emergency medical care to my child within their scope of training, and to act on my behalf to consent to any medical, hospital or emergency care or treatment deemed to be necessary or advisable for the child upon the advice of any licensed physicians, dentists, nurses, or emergency medical personnel. I also give consent for my child to be transported to an emergency medical care center if the need arises. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. I agree to indemnify and hold harmless Answers in Genesis, its employees, agents and representatives, from any and all liability in connection with such medical treatment. Parent/ Guardian Signature Date

5 Medical Information Family Physician s name Business Phone ( ) CHILD S MEDICAL HISTORY Is child in good health? List Allergies: Date of last tetanus shot: List any physical impairments (such as Heart, Epilepsy, Diabetes, etc.): Specify any medication that must be administered: Other special instructions Health Insurance company name: Policy Number Telephone

6 Be Prepared for Your Ark Encounter Overnight Participants Signed, completed permission slip Sleeping bag/blanket Pillow Sleeping bag/blanket (may bring an air mattress) Small air mattress if needed (we do not allow cots as metal cots damage wood floors) Chaperones Please note that due to security lighting, the sleeping areas do not get dark. Only a small number of electrical outlets are available in each sleeping area, please plan accordingly.

7 Participants Signed, completed permission slip Flashlight Sleeping bag/blanket Pillow Pen or pencil Clipboard/notebook (writing surface) Be Prepared for Your Overnight Chaperones Sleeping bag/blanket Flashlight Small cot or mat if needed (there is not sufficient room for everyone to have one) Please note that due to security lighting, the sleeping areas do not get completely dark. Only a small number of electrical outlets are available in each sleeping area, please plan accordingly. Male sleeping area Three C s Room (970 sq ft) Features: tile floor (carpet squares available), benches, many lights stay on, adjacent restrooms Female sleeping area Flood Geology Room (1964 sq ft) Features: carpeted floor, some lights turn off, adjacent restrooms