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Waiver for Beach Night August 16, 2019

We will be travelling in cars to Crescent Beach 

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named student.  

I/We the undersigned have legal custody of the student named below, a minor, and have given our consent for him/her to attend events being organized by the Westwinds Community Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release Westwinds Community Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Westwinds Community Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. 

 

First Students Name

First Name*

Last Name*

Phone*
First Students Date of Birth*
I certify that I am 18 years of age or older
First Students Signature*
Second Students Name

First Name*

Last Name*
Second Students Date of Birth*
Third Students Name

First Name*

Last Name*
Third Students Date of Birth*
Fourth Students Name

First Name*

Last Name*
Fourth Students Date of Birth*
Fifth Students Name

First Name*

Last Name*
Fifth Students Date of Birth*
Sixth Students Name

First Name*

Last Name*
Sixth Students Date of Birth*
Seventh Students Name

First Name*

Last Name*
Seventh Students Date of Birth*
Eighth Students Name

First Name*

Last Name*
Eighth Students Date of Birth*
Ninth Students Name

First Name*

Last Name*
Ninth Students Date of Birth*
Tenth Students Name

First Name*

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

Email*

Confirm Email*
Emergency Contact

Emergency Contact's 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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
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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