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THIS DOCUMENT CONTAINS A RELEASE, WAIVER AND INDEMNIFICATION. READ IT CAREFULLY BEFORE SUBMISSION.

Authorization. I am the Parent or Legal Guardian of the Minor Child. I do hereby voluntarily give my permission for the Minor Child to participate in the Lincoln Berean Church Youth Group ("Group") for off-site activities for the time period from August 1, 2017 to July 31, 2018. This authorization will apply on all occasions that the Minor Child participates in a Group off-site activity during the above time-period.

I understand the specific off-site activities in which the below-named student may participate may be inherently dangerous and may include, but are not necessarily limited to, the following: retreats, recreational activities, sporting activities, swimming activities and missions work.

Acknowledgment of Risks. I understand that travel to and participation in Group off-site activities by the Minor Child involves inherent risks even when reasonable safety measures are taken and it is not possible to guarantee Minor Child's safety. These risks include, but are not limited to, motor vehicle accidents, exposure to the elements present in outdoor environments, psychological injury, muscle strains, broken bones, head injury, back injury and other personal injuries. I have familiarized myself with these risks and understand these risks may be severe in nature and on rare occasions may even result in total disability, paralysis or death. I voluntarily assume all such risks on behalf of myself and the Minor Child.

Release, Waiver and Indemnification. In consideration of the Minor Child being allowed to participate in the Group off-site activities, I hereby release Lincoln Berean Church and its governing board, officers, agents, volunteers, sponsors and employees (collectively, "LBC Parties") from all actions, causes of action, damages, claims or demands that I, the Minor Child or our respective heirs, executors, administrators or assigns may have against any of the LBC Parties for all damages and injuries which I or the Minor Child may incur by traveling to and from and participating in the Group off-site activities, including, but not limited to, those outlined above under Acknowledgment of Risks, whether such injuries are caused by my negligence, the Minor Child's negligence, or the negligence of one or more of the LBC Parties. I agree to indemnify and hold harmless the LBC Parties and pay for any costs, attorney fees or awards that may result from defending any complaint or lawsuit which the Minor Child may bring against the LBC Parties for any injury the Minor Child claims to have suffered in connection with the transportation to and participation in any Group off-site activity.

Medical Treatment Authorization. I understand that I will be notified in the case of a medical emergency pertaining to my child. In the event that I cannot be reached, however, I authorize the calling of a physician and the providing of any necessary medical services in the event that my child is injured or becomes ill. In these situations, I consent to and authorize an adult leader or chaperone of the Group to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment and hospital care. I understand that the LBC Parties will not be responsible for medical expenses incurred solely on the basis of this authorization. I also understand that the designated adult activity leader or chaperone shall have the right to restrict the Minor Child from any activity that he or she does not believe is within the Minor Child's physical capabilities.

Expenses and Damages. I assume responsibility for, and agree to indemnify the LBC Parties from, any and all expenses incurred and damages caused by the Minor Child while traveling to and participating in the Group off-site activities.

Photographs and Videos. I consent to the Minor Child being photographed, audio recorded or video recorded while participating in Group off-site activities which may be used in brochures, on church/Group social media, church/Group website, as well as audiovisual productions for church/Group events, and waive any privacy rights in the display of such photographs or recordings or any claims of ownership.

Disputes. Any disputes shall be governed by Nebraska law and venued in Lancaster County, Nebraska.

Agreement to Use Electronic Means. I have agreed to submit this Authorization, Waiver and Release on behalf of the Minor Child by electronic means. By submitting this Authorization, Waiver and Release electronically, I certify that I have read this Authorization, Waiver and Release and understand all of its terms. I execute it voluntarily and with full knowledge of its significance and understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. I understand that it contains a release of liability and indemnification obligations.

I Agree
By checking this box and signing my name below, I am electronically signing the Authorization, Waiver and Release.

July 20, 2018

First Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
First Parent or Legal Guardian Date of Birth*
I certify that I am 19 years of age or older
First Parent or Legal Guardian Signature*
Second Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Second Parent or Legal Guardian Date of Birth*
Third Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Third Parent or Legal Guardian Date of Birth*
Fourth Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Parent or Legal Guardian Date of Birth*
Fifth Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Parent or Legal Guardian Date of Birth*
Sixth Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Parent or Legal Guardian Date of Birth*
Seventh Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Parent or Legal Guardian Date of Birth*
Eighth Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Parent or Legal Guardian Date of Birth*
Ninth Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Parent or Legal Guardian Date of Birth*
Tenth Parent or Legal Guardian Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Parent or Legal Guardian Date of Birth*
Parent or Guardian's Email Address

Email*
A signed copy of this waiver will be sent to the email address you provide.
Minor Child Information

Name of Minor Child *

Grade *

Date of Birth *
Parent or Legal Guardian Information

Name of Parent or Legal Guardian *

Street Address *

City *

State *

Zip Code *
Emergency Contacts when Parent or Legal Guardian Cannot be Reached

Name of Emergency Contact #1 *

Relationship to Minor Child *

Home Phone *

Cell Phone *

Name of Emergency Contact #2 *

Relationship to Minor Child *

Home Phone *

Cell Phone *
Medical Information Regarding Minor Child
Known Allergies*
Yes
No

If yes, please specify:
Current Medications*
Yes
No

If yes, please specify:
It is okay for the Minor Child to take the following:
Tylenol
Advil (Ibuprofen)

Physical Limitation or Disabilities

Medical Insurance Provider *

Phone *

Policy Number *

Policy Holder's Name *
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 19 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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