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2018 NITRO Waiver--16300 112th Avenue NE, Bothell, WA 98011

RELEASE; PAYMENT OF EXPENSES; MEDICAL CONSENT

  1. The undersigned parent(s) or legal guardian(s) (“Parent”) grants permission for their son or daughter (“Child”) to participate in the "NITRO 2.0 Kids Conference" 2019 event  (“Event”) on March 15-16, 2019, to be held at Cedar Park Assembly of God (16300 112th Avenue NE, Bothell, WA 98011) and immediate vicinity.   

  2. The Parent expressly warrants that the Child is capable of withstanding the physical demands of the activities involved at the Event, including rigorous physical activities, such as, but not limited to, outdoor sports and other physically and emotionally demanding activities, such as field games. The Parent expressly warrants that the child is capable of activities that are physically and emotionally demanding, such as, but not limited to, activities involving running, jumping and physical contact. 

  3. The Parent grants permission to Cedar Park and its employees and agents to seek and secure any medical attention or treatment for the Child including hospitalization, if in the agent’s opinion such need arises and Cedar Park is unable to contact the Parent.  The Parent gives consent to any licensed physician to administer drugs or medicine or to perform such medical procedures as that physician determines necessary for the relief of pain and to preserve the Child’s life or health. Additionally, Parent hereby grants permission for Cedar Park or its agents to administer basic medical treatment in the event such need arises, including the administration of over-the-counter medications.

  4. The Parent agrees to assume the responsibility for all medical, transportation, rescue and other related expenses incurred on behalf of the Child. 

  5. The Parent releases and agrees to hold harmless, defend and indemnify Cedar Park, its directors, officers, employees and agents from and against any and all claims for personal injury (including loss of life) and all other losses or damages (except those caused entirely by the gross negligence or intentional conduct of Cedar Park Assembly) that the Child or the Parent may suffer as a result of the Child’s participation and/or enrollment at the Event. 

  6. On occasion, Cedar Park takes photographs or makes an audio or video tape recording of children involved in church activities.  Such photographs or video records may be used by staff and participants to remember the activities or participants.  In addition, such photographs and audio/visual recordings may be used in Cedar Park publications or advertising materials to let others know about Cedar Park’s ministry.  The Parent consents to the use of any such audio or visual record of the Child named above to be used, distributed, or displayed as agents of the church see fit.  This consent includes but is not limited to: photographs, videotape, and audio recordings. 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
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 or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy 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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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