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2022

AUTHORIZATION, CONSENT, AND RELEASE FOR A MINOR

Transportation I authorize Athey Creek Christian Fellowship (ACCF), its agents, employees, and representatives to provide transportation for the child for ACCF outings. It is not necessary that I be contacted for permission each time ACCF or its agents, employees, or representatives provides transportation for a trip. For all purposes herein, all references to "child" shall mean each individual child listed below.

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

1. Contact the physician listed below and follow that physician's instructions;

2. Transport the child to a medical facility and make decisions on my behalf as to the treatment; and/or

3. Consent to treatment by the physician named below or, if that physician is not available, then ACCF is authorized to obtain and give consent for any recommended examination, care, and treatment of the child named below.

Photos and Recordings - I hereby grant ACCF permission to use the child's image, likeness, and the sound of his or her voice as recorded by audio or video recordings, or in a photograph (photos and recordings) 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 these photos and recordings 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 child's likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photos and recordings.

Release I, individually and as guardian of the child named below, 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, the child, my heirs, representatives, executors, administrators, or any other persons have or may have, including and not limited to medical costs and expenses for the child, resulting directly or indirectly from the child's participation in ACCF activities, including transportation as to those activities, and/or by reason of ACCF's use of the photos and recordings as described herein. There is no time limit on the validity of this release nor is there any geographic limitation.

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
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/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

Date of Last Tetanus Shot

Medications

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.


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/Guardian's Name

First Name*

Middle Name

Last Name*
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 to use an electronic signature. 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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