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Little Country Church Release, Waiver of Liability, and Indemnity Agreement

Authorization to Obtain Urgent or Emergency Medical Care / Medical Record and Release

The undersigned do hereby authorize, Little Country Church in Redding, staff, and volunteers, as agents for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the Minor indicated herein which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision of the MEDICINE PRACTICE ACT or of any dentist licensed under the DENTAL PRACTICE ACT, at a hospital or elsewhere. In the absence of parent or guardian, the above-mentioned agent is authorized to make decisions concerning the positive health and welfare of this minor. First aid and non-prescription medication will be administered at the adult leader's discretion.

Permission to Participate; Release, Waiver of Liability, and Indemnity Agreement

I/we give permission for Minor indicated herein to participate in the activities of Little Country Church, both on the church premises and elsewhere. In thought of the opportunity of my/our child/youth to participate in the activities of Little Country Church, I/we release Little Country Church, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for any loss or injury to my/our child/youth arising from my/our child/youth's participation in the activities of Little Country Church; and I/we agree to indemnify and hold forever harmless the Little Country Church, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for loss or injury to my/our child/youth arising from activities on or off the premises of Little Country Church or resulting from traveling to or from the activities of Little Country Church, including loss or injury resulting from negligence or gross negligence. I/we understand and agree that this permission and agreement shall remain in effect until revoked in writing by me/us, and I/we understand and agree that it is my/our responsibility to update our child/youth's medical and insurance information as changes occur.

Photo Permission

I/we understand that my child may be photographed while participating in the activities of Little Country Church. I/we give permission for a recognizable image of my child to be posted on the Little Country Church websites, bulletin boards, LCC Facebook groups, or used in promotional materials. I understand that the Little Country Church will not include my child’s last name or any identifying information. I understand that a non-recognizable image, such as a group picture, may be posted as well.

Disciplinary Agreement

I/ we understand that, while the Minor indicated herein participates in any regularly sponsored activities, or special events he or she is responsible to abide by the rules set forth by the sponsoring ministry, its leader and supervisory personnel. Any serious infraction of rules and/or conduct by the child can result in dismissal from the program. In the event your child is dismissed from the program, I/we the undersigned, agree to assume the cost of returning the child to his or her home. We also agree to forfeit any possible refund. (We understand that such action would only be taken under extreme circumstances and only after direct consultation with the child’s pastor and parent or guardians)

I/ we the undersigned am in agreement with and consent to each the above items; Authorization to Obtain Urgent or Emergency Medical Care / Medical Record and Release, Permission to Participate; Release, Waiver of Liability, and Indemnity Agreement, Photo Permission and Disciplinary Agreement. This authorization will remain effective while the above minor is in the care of Little Country Church in Redding from the dates December 31, 2024 through and including December 31, 2025 unless revoked in writing by the undersigned, and delivered to the aforesaid agent.

Today's Date: January 22, 2025


First Parent/Guardians Name

First Name*

Middle Name

Last Name*

Phone*
First Parent/Guardians Age Acknowledgment*
First Parent/Guardians Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardians Signature*
Second Parent/Guardians Name

First Name*

Middle Name

Last Name*
Second Parent/Guardians Date of Birth*
Third Parent/Guardians Name

First Name*

Middle Name

Last Name*
Third Parent/Guardians Date of Birth*
Fourth Parent/Guardians Name

First Name*

Middle Name

Last Name*
Fourth Parent/Guardians Date of Birth*
Fifth Parent/Guardians Name

First Name*

Middle Name

Last Name*
Fifth Parent/Guardians Date of Birth*
Sixth Parent/Guardians Name

First Name*

Middle Name

Last Name*
Sixth Parent/Guardians Date of Birth*
Seventh Parent/Guardians Name

First Name*

Middle Name

Last Name*
Seventh Parent/Guardians Date of Birth*
Eighth Parent/Guardians Name

First Name*

Middle Name

Last Name*
Eighth Parent/Guardians Date of Birth*
Ninth Parent/Guardians Name

First Name*

Middle Name

Last Name*
Ninth Parent/Guardians Date of Birth*
Tenth Parent/Guardians Name

First Name*

Middle Name

Last Name*
Tenth Parent/Guardians Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Medical Information

IMPORTANT: If waiver is for multiple students, clarify which information applies to each student.


Will medications be needed for you student?*
No
Yes

Medication that the above-mentioned minor is required to take will be turned over to the Camp Nurse when you arrive at camp. Including natural supplements (like melatonin). Type of medication and specific instructions:

Allergies/special health concerns including reactions to medications:

Medications your child CANNOT take:
Occasionally, it is nessesary to provide a child with non-prescriptive medications when they are at camp. Please CHECK below to indicate whether you give permission FOR the listed medications to be administered by the camp nurse. We will not administer any medication without this authorization.
Benadryl (itching, cold/allergy symptoms)
Cortisone Cream (Itching, bug bites)
Neosporin (Cuts/scrapes)
Tums (Upset Stomach)
Cough Drops
Ibuprofen (Head/muscle aches)
Pepto Bismol (Upset Stomach)
Tylenol (Head/muscle aches)

First aid and non-prescriptive medication will be administered at the adult leader's discretion, with the following exceptions:
I/we understand that my child may be photographed while participating in the activities of Little Country Church. I/we give permission for a recognizable image of my child to be posted on the Little Country Church websites, bulletin boards, LCC Facebook groups, or used in promotional materials. I understand that the Little Country Church will not include my child’s last name or any identifying information. I understand that a non-recognizable image, such as a group picture, may be posted as well.*
Yes
No
Insurance

Insurance Carrier*

Insurance Policy Number*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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