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2023-2024 PERMISSION AGREEMENT & RELEASE OF LIABILITY

On The Rock Ministries

PERMISSION AGREEMENT AND RELEASE OF LIABILITY:

IN CONSIDERATION of being allowed to participate, for which we hereby apply, in On The Rock Ministries, Inc., and related activities including receiving free transportation to said activities, we, the participant and his/her undersigned parent/guardian (if participant is not 18 or older), hereby acknowledge that we, with full knowledge and understanding of the risks involved, have voluntarily applied for the participant to participate in Rock related activities/events being conducted by On The Rock Ministries, Inc., from school to “The Rock” and to other locations for related activities; and the undersigned parent further grants his/her permission for the undersigned participant to participate in said program and related activities;  AND, we further do hereby for ourselves, our heirs, personal representatives, successors and assigns, HEREBY RELEASE, FOREVER DISCHARGE AND HOLD HARMLESS On The Rock Ministries, Inc. its successors, assigns, employees, directors, officers, agents, and volunteers and their heirs, successors, and assigns (both individually and in their corporate capacity) from any and all manner of claims, demands, damages, causes of action, suits, judgments and costs including attorney’s fees, by reason of any matter or thing whatsoever, and particularly growing out of or in anywise connected with, directly or indirectly, the aforesaid child’s participation in On The Rock Ministries, Inc. related activities including receiving free transpiration to said activities.

I Agree
to PERMISSION AGREEMENT AND RELEASE OF LIABILITY

 

 

ASSUMPTION OF THE RISK AND WAIVER OF THE LIABILITY RELATED TO CORONAVIRUS/COVID-19:

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. The Rock has put in place preventative measures to reduce the spread of COVID-19; however, the Rock cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Rock could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Rock and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Rock may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Rock employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Rock or participation in Rock programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Rock, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Rock, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Rock program.

I Agree
 to ASSUMPTION OF THE RISK AND WAIVER OF THE LIABILITY RELATED TO CORONAVIRUS/COVID-19

 

 

MEDIA RELEASE:

We hereby voluntarily release and forever allow On The Rock Ministries, Inc., to use, at its sole discretion, any and all photographic materials, and/or video materials taken of participant, in any manner On The Rock Ministries, Inc. deems suitable. We fully understand that this may include, but not be limited to, use of said material in a magazine, newspaper, newsletter, flyer, brochure, promotional literature, news programs, documentaries or other type of publication

I Agree
 to MEDIA RELEASE

 

 

MEDICAL RELEASE: 

In the event that I cannot be reached in an emergency, I hereby give permission to any licensed physician, surgeon, clinic, or hospital to secure proper treatment, and to order anesthesia, for my child/myself as named above.

I Agree
 to MEDICAL RELEASE

 

 

PROGRAM END TIME:

I understand participants must leave or be picked up before 6:00 pm.

I Agree
 to PROGRAM END TIME

 

 

SKATE PARK RELEASE:

Release of Liability, Waiver of Claims and Indemnity Agreement In consideration for being permitted to participate in the above described activity(ies) and related activities, I hereby agree, acknowledge and appreciate that: 1. I HEREBY RELEASE AND HOLD HARMLESS WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY NEGLIGENCE OR OTHERWISE, the following named persons or entities, herein referred to as releasees. On the Rock Ministries, Inc. Owner (Company and/or Person) 2. To release the releasees, their officers, directors, employees, representatives, agents, and volunteers from liability and responsibility whatsoever and for any claims or causes of action that I, my estate, heirs, survivors, executors, or assigns may have for personal injury, property damage, or wrongful death arising from the above activities whether caused by active or passive negligence of the releasees or otherwise. By executing this document, I agree to hold the releasees harmless and indemnify them in conjunction with any injury, disability, death, or loss or damage to person or property that may occur as a result of my engaging in the above activities. 3. By entering into this Agreement, I am not relying on any oral or written representation or statements made by the releasees, other than what is set forth in this Agreement. 4. This agreement shall apply to any and all injury, disability, death, or loss or damage to person or property occurring at any time after the execution of this agreement. This release shall be binding to the fullest extent permitted by law. If any provision of this release is found to be unenforceable, the remaining terms shall be enforceable. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, I FULLY UNDERSTAND ITS TERMS, I UNDERSTAND THAT I HAVE GIVEN UP LEGAL RIGHTS BY SIGNING IT, AND I SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 

I Agree
 to SKATE PARK RELEASE

If you do not wish to allow your student access to the skate please still mark agree, but no on students information form.

 


First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Info

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Third Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Fourth Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Fifth Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Sixth Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Seventh Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Eighth Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Ninth Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
Tenth Participant's Name

First Name*

Middle Name

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

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
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, and new about activities at The Rock
Contact Numbers

Parent or Guardian Number *

Parent or Guardian Number

Parent or Guardian Number
Emergency Contact

Name/Relationship *

Number *

Name/Relationship

Number
Medical Information (not required)

Special Alerts or Restrictions
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*

Middle Name

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Info

Age *

Grade *

School *
Allow access to Skate Park*
No
Yes
Allow to sign themselves out*
No
Yes
Older sibling may sign them out
Race *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Decline to answer
Ethnicity*
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Decline to answer
Free or Reduced Lunch*
No
Yes
Decline to Answer
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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