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This waiver is to grant Christ Community Church Little Rock to use my name and/or images on Christ Community Church website and/or print material.

I hereby grant, voluntarily and with full understanding, to Christ Community Church Little Rock, a license to the following:

Use and storage of my/my child(ren)'s name  and image, by means of digital or film photography, video photography, audio recording or other documentation, with respect to the activity, namely: C3 Students (“Activity”), of Christ Community Church Little Rock.

Use of any stored data including my/my child(ren)'s name and image in printed publications of Christ Community Church Little Rock.

Use of any stored data including my/my child(ren)'s name and image in electronic publications of Christ Community Church Little Rock.

Use of any stored data including my/my child(ren)'s name and image in any website created by or for Christ Community Church Little Rock for its sole benefit.

If I am signing this agreement on behalf of a minor child, I hereby warrant that I am the legal parent or guardian of the child and that I have the legal authority to sign this agreement on behalf of the child.

First Participant's Name

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

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

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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 or Guardian's Name

First Name*

Last Name*

Relationship*

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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