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REQUIRED PERMISSION FORM
Domestic/Minor Travel 

General Release and Hold Harmless Agreement

Heartland Ministry: Heartland Students
Dates of Travel: 06/26/2021
Heartland Trip Leader: Nick Scheske  

I am the parent or legal guardian of (the "Minor"), who desires to participate in various programs, events or activities Inside the United States (hereinafter collectively referred to as the "Activities") operated or sponsored by Heartland Church.

I understand and acknowledge that the Church will not allow the minor to participate in the Activities without releasing and holding the Church harmless from any liability arising out of participation in the Activities. I have investigated the risks involved in the Minor's participation in the Activities and fully understand and assume such risks on my behalf. Specifically, I understand and acknowledge that the Minor may suffer or experience, among other things, personal injury or bodily damage, medical disabilities, loss or theft of personal property, imprisonment, abduction and even death. 

I REQUEST THAT THE CHURCH ALLOW THE MINOR TO PARTICIPATE IN THE ACTIVITIES, AND IN CONSIDERATION THEREOF AGREE HEREBY TO RELEASE AND FOREVER DISCHARGE THE CHURCH, ITS OFFICERS AND DIRECTORS, AND ITS EMPLOYEES, AGENTS, AND ANY PARTIES VOLUNTEERING ON BEHALF OF THE CHURCH, FROM ALL ACTIONS, CAUSES OF ACTION, INJURIES, CLAIMS, DAMAGES, RANSOM DEMANDS, COSTS OR EXPENSES OF ANY KIND, GROWING OUT OF OR RELATED TO ANY SUCH ACTIVITIES IN WHICH THE MINOR PARTICIPATES. I UNDERSTAND THAT THIS IS A FULL AND COMPLETE RELEASE OF ALL INJURIES AND DAMAGES WHICH I OR THE MINOR MAY SUSTAIN AS A RESULT OR 11S/HER PARTICIPATION IN ANY OF THE ACTIVITIES, REGARDLESS OF THE SPECIFIC CAUSE THEREOF. 

I acknowledge and agree that I have given my consent for the Minor to remain in the custody of the Church's representatives while participating in the Activities. 

This Agreement is binding on the Minor's Heirs, Successors and Personal Representatives.

MEDICAL TREATMENT AUTHORIZATION AND POWER OF ATTORNEY

In the event the Minor suffers any injury or condition during his or her participation in the Activities, including transportation to and from the Activity, which may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort or medical treatment is delayed, and reasonable attempts to contact me and my spouse have been unsuccessful, I hereby appoint the Heartland Trip Leader as my agent to act for me and in my name (in any way I could act in person) to make any and all decisions for the Minor concerning his or her personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate when the Agent is first able to contact me or my spouse. 

PHOTOGRAPHY RELEASE

Regarding photographs of the Minor taken at any Heartland Church event, I give Heartland Church permission to do the following for nonprofit use and without charge: use at the discretion of Heartland Church, display at a service or event or be used in a multimedia presentation, reprint and distribute for any Heartland Church nonprofit publication with copyright to accompany photo when used, display on the Heartland Church website, or use quotes and video clips on the Heartland Church website and weekend annuncments. 

The undersigned agrees to the above Initialed sections and this agreement is binding on my Heirs, Successors and Personal Representatives. 

Today's Date: June 18, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First 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*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone 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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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