WAIVER AND PERMISSION FORM Student Programs and Activities

WAIVER AND PERMISSION FORM

Student Programs and Activities

Date:

Student/Participant Information

Name: _______________________________________

Address: ____________________________________ City:_ State: Zip .

Phone (H): _ (C): _ Email: .

Date of Birth / / School: Church/Campus: .

Emergency Contact

Parent/Legal Guardian: __ Phone: .

Alternate Contact: __ Phone: .

Medical Information (to be completed by parent/legal guardian)

Emergency Medical Information: (i.e. allergies, medication, physical limitations, etc.)

__________________________________________________________________________________________________

Health Insurance: Insurance ID# & Group: .

Participation Agreement:

I understand that by participating in this activity, the Student/Participant is required to consent and abide, by all the guidelines,

procedures and decisions run and established by the The Life Church DC (TLC) Leadership, Student Ministry Leaders and

Volunteers. Non-compliance of a guideline, procedure and timely conformity to a leadership decision may result in the following:

Parent/Guardian will be called to immediately pick-up Student/Participant; participation in future Student Ministry and other

TLC activities may be limited and/or not allowed; other appropriate measures which are deemed necessary for the safety of the

Student, TLC and the Student Ministry. The Student and Parent/Guardian understand, agree and consent, that TLC, Student

Ministry Leaders and volunteers have no responsibility for, and are not obligated in any way, now or in the future, to provide

financial, and other type of assistance for, personal injury, personal property loss or damage during this conference. The

Student/Participant and Parent/Legal Guardian agree to be responsible for any damage caused by the Student to equipment,

supplies and other resource, and will immediately make all requested restitutions to, at TLC option, obtain, repair all/any damage

caused.

Release and Indemnification:

I recognize that by participating in Student Programs and Activities, as with any group activity, my student may risk serious, or

even fatal, personal injury. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge

of the risks involved in Student Programs and Activities, and that I assume any expenses that may be incurred in the event of an

accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

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WAIVER AND PERMISSION FORM

Student Programs and Activities

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I, for myself, my child, my executors and assigns, further agree to release and forever discharge The Life Church DC (TLC) and

its staff, leaders and volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to

any injury, damages, demands or actions whatsoever, including those resulting from negligence by TLC and its staff, leaders and

volunteers, in any manner.

All matters regarding non-compliance of the statements expressed in this form will be first submitted for decisions by TLC

Leadership, TLC Board, and, if further decided by TLC Leadership, Christian arbitration with a competent arbiter chosen by

TLC in accordance with Article XI of the Bylaws. Any and all matters pertaining this and other activities of TLC are subject to

the State of Virginia laws. Student/Participants consent and agree that, if they would use the State of Virginia court system, all

legal request will be handled by one of its official courts in the northern Virginia counties.

I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.

Medical Treatment Consent:

I, being the parent/guardian of the said student, understand that while every precaution will be taken to ensure the welfare and

protection of my student, The Life Church DC (TLC), its staff, leaders and volunteers acting on my behalf, as a service to my

student and all participants, may assist in getting medical health help, and are hereby completely released from any and all

liability, indemnity and restoration request, now and in the future, in the event of any accident or misfortune that may occur to

my student/participant. In the case of an emergency, I hereby give permission for medical treatment and/or transport by TLC

and/or First Responders to ensure proper treatment for my student. I understand that every effort will be made to contact me

before instituting such procedures. I agree to pay, and reimburse all such doctor, ambulance, hospital, and other related fees

incurred on behalf of my student.

PARENT/GUARDIAN NAME (please print): ____________________________________________________

PARENT/GUARDIAN SIGNATURE: _____________________________________ Date: _______________

Note: The Life Church DC reserves any and all rights, privileges, now and in the future, to supplement, revise this and other

forms used for TLC activities, and, may take additional steps, as its own discretion. Any action/steps/decision taken by TLC does

not affect the rest of the permission/indemnity sections.

Intending to glorify God in all we do (1 Cor 10:31), The Life Church DC endeavors to comply with all pertinent federal, state

and local laws that preserve the right to privacy and personal information. TLC’s Information practice conforms and governs the

collection, maintenance, use, and dissemination of personally identifiable information (PII) about individuals and families and is

strictly maintained in secured systems of records. TLC’s strives to manage information, data, and processes, and do its activities

with integrity and excellence.

WAIVER AND PERMISSION FORM

Transportation Addendum

This Transportation Addendum is an extension of the Student Programs and Activities Waiver and Permission Form. By signing

this Addendum, the Parent/Legal Guardian of the Student agrees that the Participation Agreement, Release and Indemnification,

and Medical Treatment Consent included in the attached the Student Programs and Activities Waiver and Permission Form

equally apply to the transportation of the named Student.

Date:

Student/Participant Name: _______________________________________

I authorize The Life Church DC to transport my minor student in a church or private vehicle, driven by an individual

authorized by The Life Church DC, to and from student activities, between TLC Campuses and between any TLC

Campus and the location of any student activity. I understand my child is expected to follow all applicable laws

regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or

volunteers.

I have read, understand, and discussed with my child the following rules: (1) My child will travel in a motor vehicle

driven by an adult and my child is to wear their safety belt during travel (if vehicle so equipped); (2) My child is

expected to listen to the supervising staff/driver, to respect staff and other children, the vehicles they ride in, and the

people they travel with during the trip; and (3) my child is to remain in their seat and not be disruptive to the driver

of the vehicle.

I have read the entire Student Activities Permission Form (attached) and this Transportation Addendum, fully

understand them, and agree to be legally bound by their terms.

PARENT/GUARDIAN NAME (please print): ____________________________________________________

PARENT/GUARDIAN SIGNATURE: _____________________________________ Date: _______________

Note: The Life Church DC reserves any and all rights, privileges, now and in the future, to supplement, revise this and other

forms used for TLC activities, and, may take additional steps, as its own discretion. Any action/steps/decision taken by TLC does

not affect the rest of the permission/indemnity sections.