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LIABILITY, MEDICAL AND PHOTO RELEASE FORM

Department or Activity: First Love Skate Night (September 2022 - March 2023)

Liability and Medical Release:

We (I) do hereby release, forever discharge and agree to hold harmless Portland Christian Center (Church), the staff and volunteers from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said participant is participating in the above described trip or activity. Furthermore, we (I), assume all risk of personal injury, sickness, death, damage and expense as a result of participation in transportation, recreation and work activities involved therein. Further, authorization and permission is hereby given to said Church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree(s) to hold harmless and indemnify said Church, its directors, employees and agents, for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

We (I), hereby grant our (my) permission for my child to participate fully in Portland Christian Center’s trip or activities, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, family emergencies, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

Today's Date: March 24, 2023 




First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Third Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Fourth Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Fifth Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Sixth Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Seventh Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Eighth Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Ninth Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Tenth Participant's Name

First Name*

Middle Name

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

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
I agree to follow the rules of the First Love Skate Nights
You must agree to ALL of these areas to participate. *
I will not bring drugs or alcohol into the building
If I decide to leave the building after I come in, I understand that I will NOT be allowed to re-enter for the remainder of the evening.
I will respect the leaders and the other skateboarders at Skate Night. This includes not being a distraction during the message time.
I will not be involved in a fight. If I am, I understand that I may be asked to leave for the night.
I understand that Thursdays are for High School only and that Friday is for Middle School only.
Which grade is your skater currently in:
First participant's grade*
Second participant (if applicable)
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 Legal 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 or Legal Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parents/participants over 18, please provide a photo of the front of your driver's license.
  
Parents/guardians: this is to insure that you are aware of this waiver and that your signature matches. *
Valid file types: JPG, GIF, PNG, and PDF

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 I am also confirming that I am the parent and/or legal guardian of the minor represented in this document.




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 Legal Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Legal Guardian's Date of Birth*
Parent or Legal Guardian's Information

Medical information of participant: 


Allergies

Special instructions or medical conditions

Medications including dosage and instructions

Photo Release 

I acknowledge and agree to the following: I hereby grant permission to Portland Christian Center (Church) to use my or my child's photograph(s), video or audio recording on its website or in any other official Church sites, videos, slides, recordings, printed publications, or any record of my participation in Church activities for legitimate purposes and without further consideration. I acknowledge the Church's right to crop or treat the photograph(s) at its discretion. I also acknowledge that the Church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. The Church reserves the right to discontinue use of any photograph(s) without notice. I also understand that once my or my child's image is posted on the Church's website or social media, the image can be downloaded by any computer user. I therefore indemnify and hold harmless Portland Christian Center, the Assemblies of God denomination and any employee, agent, or representative thereof from claims arising out of the use of my or my child's photograph(s). You may request a copy of our Digital / Audio / Photography policy from the Church office. I understand that my consent is in effect until such time that I inform Portland Christian Center in writing to discontinue the use of my or my child's photograph(s).
I agree

Media Opt-Out

If you, or your child choose, to opt out of the photo release for you or your child please sign here and include a photo to be used by Portland Christian Center to confirm identity of those to not be included in this opt-out option:
I choose to opt out of the Photo Release and will provide photo to be used.
Parent or Legal 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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