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KCA Student Event Waiver

Student Information
Student Name *
Student Name
Child/ Student Birth date *
Child/ Student Birth date
Parent/ Guardian Information
Guardian Name *
Guardian Name
Home Address *
Home Address
Primary Contact *
Primary Contact
Primary Contact Phone *
Primary Contact Phone
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
Activity Agreement
FUNCTIONS & ACTIVITIES: It is my understanding that participating in the programs and recreational and other activities of KELSO CHRISTIAN ASSEMBLY is a privilege. Prior to my child/ youth’s participation in such activities, I acknowledge that there are certain risks associated with the activities including, by way of example, physical injury due to activity related accidents, physical injury due to transportation related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. REALEASE OF LIABILITY: By signing this Permission/ Waiver Form, I expressly warrant that the child/ youth named above is capable of withstanding the physical demands of the activities discussed above. I also expressly assume all risks of the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release KELSO CHRISTIAN ASSEMBLY and its ministers, leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless KELSO CHRISTIAN ASSEMBLY and its ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities. EMERGENCY MEDICAL TREATMENT: I recognize that there may be occasions where the child named above may be in need of first aid or medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of KELSO CHRISTIAN ASSEMBLY to seek and secure any medical attention or treatment for the child named above, including hospitalization, if in the agent’s opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physicians (s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment. SPECIAL AND OFFSITE EVENTS: I understand that the child/ youth named above will be participating in various activities from within the calendar year dated by the approving signature I will sign in the form below. I understand that during this period my child/ youth may take part in activities such as: Snow Camp, Youth Convention, and other activities consistent with the purposes of the church. I also understand that I may be asked to sign Special Permission Slips in addition to this form. PUBLICITY: On occasion, KELSO CHRISTIAN ASSEMBLY takes photographs or makes an audio or video tape recording of children and/ or adults involved in church activities. Such photographs or video records may be used by staff and participants to remember the activities or participants. In addition, such photographs and audio/visual recordings may be used in KELSO CHRISTIAN ASSEMBLY publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our church may invite or allow them to photograph or record our events for news reporting or special interest features. I consent to the use of any such audio or visual record of the child named above to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media.
Medical Information
If EPI PEN or other medical treatment is required in severe instances please list below.
Diabetes, Blood Disorders, Special Needs, Ect.
Diabetes, Blood Disorders, Special Needs, Ect.
Primary Doctor Phone
Primary Doctor Phone
Liability Agreement
GUARDIAN AUTHORIZATION I represent that I am the parent/ guardian of the above child, who is under 18 years of age. I have read the above Permission/ Waiver Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of KELSO CHRISTIAN ASSEMBLY, including any special events/ activities described above. In consideration for allowing the participation of the child in the activities of KELSO CHRISTIAN ASSEMBLY, I hereby consent to the Permission/ Waiver Form, including the Release of Liability above, on behalf of the child, and agree that this Permission/ Waiver form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns. I also understand that it is my responsibility to see that the information on this form is updated when there are any changes in my child’s/ youth’s medical status, etc. STUDENT AGRREMENT I agree to participate in the functions and activities of KELSO CHRISTIAN ASSEMBLY, to cooperate with the leaders and other young people and to conduct myself as a Christian. I promise to respect God, other persons, and property. I understand that my continued participation depends on my support of this agreement.
Legal Guardian Signature *
Legal Guardian Signature
By signing I AGREE to the LIABILITY AGREEMENT listed above as well as the listed ACTIVITY AGREEMENT. By signing I also claim to have Legal Authority to sign this agreement on behalf of the listed student/child.
Signature Date *
Signature Date
Student Signature *
Student Signature
Signature Date *
Signature Date