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2019

AUTHORIZATION, CONSENT AND RELEASE

Transportation I authorize Athey Creek Christian Fellowship (ACCF), its agents and employees to provide transportation for ACCF outings.

Medical Treatment In the event that an illness or injury befalls the individual, either on or off the Fellowship's premises, ACCF should contact the guardian, friend, or relative listed below to make arrangements for the individual's care. If none of those persons can be quickly located, or in the case of an emergency, I authorize ACCF to:

1. Transport me to a medical facility and make decisions on my behalf as to the treatment.

2. ACCF is authorized to obtain and give consent for any recommended examination, care, and treatment.

Photography - I hereby grant ACCF permission my image, likeness, and the sound of my voice as recorded by audio or video recordings, or in a photograph in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of ACCF, are copyright protected by ACCF, and will not be returned. I hereby irrevocably authorize ACCF to edit, alter, copy, exhibit, publish or distribute this photo (or photos) for purposes of publicizing ACCF's programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein the individual likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph(s).

Release I hereby hold harmless, waive, release, and forever discharge ACCF (its employees, agents and representatives) from any and all claims, demands, liability, causes of action, and damages which I, my heirs, representatives, executors, administrators, or any other persons have or may have, resulting directly or indirectly from myparticipation in ACCF activities, including transportation as to those activities, and/or by reason of ACCFs use of the photography and/or audio/video as described herein. There is no time limit on the validity of this release nor is there any geographic limitation.

First Individual's Name

First Name*

Middle Name

Last Name*

Phone*
First Individual's Date of Birth*
First Individual's Signature*
Second Individual's Name

First Name*

Middle Name

Last Name*
Second Individual's Date of Birth*
Third Individual's Name

First Name*

Middle Name

Last Name*
Third Individual's Date of Birth*
Fourth Individual's Name

First Name*

Middle Name

Last Name*
Fourth Individual's Date of Birth*
Fifth Individual's Name

First Name*

Middle Name

Last Name*
Fifth Individual's Date of Birth*
Sixth Individual's Name

First Name*

Middle Name

Last Name*
Sixth Individual's Date of Birth*
Seventh Individual's Name

First Name*

Middle Name

Last Name*
Seventh Individual's Date of Birth*
Eighth Individual's Name

First Name*

Middle Name

Last Name*
Eighth Individual's Date of Birth*
Ninth Individual's Name

First Name*

Middle Name

Last Name*
Ninth Individual's Date of Birth*
Tenth Individual's Name

First Name*

Middle Name

Last Name*
Tenth Individual's Date of Birth*
Individual'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/Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent/Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Medical

Allergies
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/Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent/Guardian's Date of Birth*
Parent/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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