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YOUTH FOR CHRIST/USA, INC. – CONSENT AND RELEASE OF LIABILITY

Permission to participate - Recognize accidents may happen when doing fun stuff and accept risks – Choose to come healthy - Hold YFC harmless - Consent to emergency medical treatment and costs – Media release - Behavior agreement for safety

1. RELEASE OF LIABILITY - “I give my permission to participate in YFC activities. I understand accidents can happen when doing fun activities and accept the risks. I or my child agree to come to YFC activities healthy.”

I understand that the opportunity to participate in YOUTH FOR CHRIST/USA, INC., et al (“YFC”) activities is a privilege. I am signing this Release of Liability form on behalf of myself or my minor child. I understand that my child or I may participate in any number of physical activities some of which include, but are not limited to, recreational activities and games and events. I understand that there are certain risks of physical injury or illness associated with these activities. In addition, I understand that there may be other risks associated with activities of which I may not be presently aware.

By signing this Release, I expressly assume these risks for myself or my minor my child, whether they are known or unknown to me at this time and certify that I or my child is healthy and fit to participate in all YFC activities. I release YOUTH FOR CHRIST/USA, INC., including its affiliated chapters, affiliates, and their officers, directors, volunteers, employees, contractors and agents, from any claim that I or my child may have now or in the future against them for any accidental physical or other personal injury, loss of personal property, illness or death caused by infectious and/or contagious diseases or sickness while at camp or other YFC activities, or during YFC travel to and from camp or other YFC activities, and any medical responses to the same, as well as any other claims arising from participation in YOUTH FOR CHRIST/USA, INC. et al activities. This release of liability shall cover (without limitation) all claims for negligence and breach of fiduciary duty asserted by my child, myself or any person made on their behalf. This Release specifically covers claims caused in whole or in part by any U.S. national health crisis, epidemic, pandemic, or similar widespread outbreak of disease whether or not such is formally declared by the U.S. government, the Center for Disease Control or the World Health Organization. YFC reserves the right to follow recommended CDC guidelines related to such pandemic, outbreak or disease and as such may choose at any time to send a participant home if presenting signs of sickness.

2. INDEMNIFICATION – “I agree to hold YFC harmless.”

I hereby agree to defend, indemnify and hold YOUTH FOR CHRIST/USA, INC., including its chapter affiliates, their directors, volunteers, employees, contractors and agents, harmless from any liability asserted by me or my child subsequent to his or her 18th birthday, including reasonable attorney's fees and costs.

3. AUTHORIZATION FOR MEDICAL TREATMENT - “If an accident happens and if I cannot be reasonably reached, I give permission for emergency medical treatment and promise to cover medical costs if treatment is needed.”

I understand it may be necessary to have a medical consent form present for medical professionals in the unlikely event of an injury or condition requiring medical treatment of me or my child. This form gives YFC and its personnel the permission to take me or my child to the nearest, capable medical facility and have any necessary emergency treatment administered.

IF PARTICIPANT IS A MINOR: IN CASE OF EMERGENCY, I UNDERSTAND THAT EFFORTS WILL BE MADE TO CONTACT ME; HOWEVER, IF I CANNOT BE REACHED, I HEREBY GIVE YOUTH FOR CHRIST/USA, INC. AND ITS REPRESENTATIVES THE PERMISSION TO ACT ON MY BEHALF IN SEEKING EMERGENCY MEDICAL TREATMENT FOR MY CHILD IN THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY OR ADVISABLE FOR MY CHILD'S HEALTH, SAFETY AND WELFARE. I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO, USING THE MEASURES DEEMED NECESSARY. I RELEASE YOUTH FOR CHRIST/USA, INC., ITS REPRESENTATIVES, AND ALL MEDICAL PROVIDERS FROM LIABILITY IN ACTING IN THIS REGARD AND RENDERING SUCH MEDICAL TREATMENT. I WILL BE FULLY RESPONSIBLE FOR ALL SUCH MEDICAL EXPENSES.

IF PARTICIPANT IS 18 OR OVER: IN CASE OF EMERGENCY, AND AM UNABLE TO REPRESENT MYSELF, I HEREBY GIVE YOUTH FOR CHRIST/USA, INC. AND ITS REPRESENTATIVES THE PERMISSION TO ACT ON MY BEHALF IN SEEKING EMERGENCY MEDICAL TREATMENT FOR MY PERSON IN THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY OR ADVISABLE FOR MY HEALTH, SAFETY AND WELFARE. I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO, USING THE MEASURES DEEMED NECESSARY. I RELEASE YOUTH FOR CHRIST/USA, INC., ITS REPRESENTATIVES, AND ALL MEDICAL PROVIDERS FROM LIABILITY IN ACTING IN THIS REGARD AND RENDERING SUCH MEDICAL TREATMENT. I WILL BE FULLY RESPONSIBLE FOR ALL SUCH MEDICAL EXPENSES.

4. BEHAVIORAL AGREEMENT – “YFC hates sending participants home, but sometimes they have to. I recognize that.”

I understand that illegal or behavioral issues may result in the named participant being sent home at the expense of the parent/guardian. Activities would include but are not limited to: reasonable belief of possession and/or use of drugs, alcohol, weapons; sexually aggressive and/or inappropriate behavior; stealing; fighting; etc. YFC leaders will make reasonable effort to contact the parent/guardian to make arrangements before a participant is sent home.

I Agree


Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 19 years of age or older
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Data & Survey Agreement

I hereby authorize ReBalance/Northern Colorado Youth for Christ,

When I or my child participate in surveys regarding the activities of NCYFC/Rebalance programing, the data can be used by NCYFC/Rebalance staff provided the identity of myself and my child will not be disclosed. In the furtherance of this, I allow data obtained to be used by an outside research lab to provide non-identifiable survey summaries. UNDER NO CIRCUMSTANCES SHALL THE IDENTITY OF MY CHILD BE DISCLOSED TO ANYONE FROM THESE SURVEYS. *
Yes
I give consent for the staff and volunteers of NCYFC/ReBalance to keep electronic notes in regard to their interactions with my child. I give consent for these notes to be shared with agencies or schools or individuals involved with my child.*
Yes

to, release to: any partnering agency/individual/organization who is also working with my child,

for the purpose of coordinating best possible care and mentor/transition relationship.*
Yes
I understand that I may revoke this consent at any time by giving written notice to the person or organization making this disclosure. If the client refuses to sign ROI to allow communication with partnering agencies/individuals/organizations, services cannot be provided. This consent will automatically expire five (5) years after the date of my signature as it appears below: NOTICE: This information has been disclosed from confidential records. Any further disclosure without the specific written consent of the person to whom it pertains exceeds the limits of this release. However, there are legal and ethical requirements that professionals take responsible action in those situations as prescribed by law: 1) where there is danger of imminent harm to self or others 2) in the case of apparent child/ elder abuse 3) court-ordered.*
Yes
MEDIA RELEASE - “YFC can use pictures and other media of me or my child participating in YFC activities for promotional purposes. I hereby grant permission to YOUTH FOR CHRIST/USA, INC. the right to use, reproduce, and/or distribute any photographs, film, video and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of YOUTH FOR CHRIST/USA, INC.*
Opt Out
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*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 19 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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