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Northwest Project Timothy

Liability Waiver

YOUTH ACTIVITIES CONSENT FORM

I, as parent/legal guardian of the minor(s), understand that my child will be attending Project Timothy at The Hope Vineyard in Hillsboro, OR. I understand that during this time he/she will be accompanied by volunteers from this and other Vineyards in our region under the direction of staff and volunteers from The Hope Vineyard.

I hereby release The Hope Vineyard as well as any other Vineyard church who provides volunteer staff, their staff and volunteers, and any sponsors of the event, from responsibility and liability for any loss, injury, or illness that my child may sustain during any activity. In the event of an emergency, I understand that every reasonable effort to contact me will be made. In the event that I am unable to be contacted, I hereby authorize an adult leader, as agent for me, to consent to any medical, dental, or surgical diagnosis; X-ray examination; and/or hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state or province where the services are rendered, either at the doctor's office or in any hospital.

Youth Pledge

I hereby pledge to uphold all policies of the Youth Department of Hope Vineyard. During all youth activities and all youth trips, I pledge to follow all instructions of the youth leader and the adult chaperones, including safety instructions.

Dated: September 17, 2021

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Medical Information

Is your youth presently being treated for an injury or sickness or taking any medication? *
Yes
No
Does your youth have, or has your youth ever had, any of the following? (Please check all that apply.)
Asthma
Diabetes
Hay Fever
Heart Murmur
Kidney Disease
Seizure Disorders

Please explain.
Does your youth ever sleepwalk? *
Yes
No

Youth's blood type (if known)
Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity? *
Yes
No

If yes, please explain.

Note to Parent: If giving consent for one activity only, or if this consent is otherwise restricted, please specify:
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Family Doctor

Name *

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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Medical Information

Is your youth presently being treated for an injury or sickness or taking any medication? *
Yes
No
Does your youth have, or has your youth ever had, any of the following? (Please check all that apply.)
Asthma
Diabetes
Hay Fever
Heart Murmur
Kidney Disease
Seizure Disorders

Please explain.
Does your youth ever sleepwalk? *
Yes
No

Youth's blood type (if known)
Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity? *
Yes
No

If yes, please explain.

Note to Parent: If giving consent for one activity only, or if this consent is otherwise restricted, please specify:
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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