My child has permission to attend all church-sponsored children and/or youth activities communicated by Northside Baptist. NOTE: If it is your desire to limit your child’s participation in any event, please submit your wishes in writing to Northside Baptist Church of Mechanicsville Virginia, Inc. (hereafter referred to as 'Northside') prior to that event.
Waiver and Liability Form
I (We) acknowledge that my child’s participation in an activity sponsored by Northside is voluntary and may require involvement in activities that require traveling or physical exertion. Therefore, in consideration of my child’s being allowed to participate in our church program activities, I (we) agree to the following: (Please initial below.)
Northside is not responsible for the loss or theft of personal belongings.
I understand and authorize that my child’s image may be photographed or filmed and used in video presentations, printed publications and the annual photo directory, including the church’s internet website.
I hereby take the following action for my child, myself, my executors, administrators, heir, next of kin, successors and assigns: (1) I waive, release and discharge from any and all claims or liabilities for death or personal injury damages of any kind, which arise out of or relate to my child’s participation in Northside activities; (2) I indemnify and hold harmless Northside and its staff and volunteers from any claims made or liabilities assessed against them as a result of my child’s actions.
I hereby assume the risks of my child participating in all activities sponsored by Northside. The undersigned parent or guardian of (the minor), hereby executes this document for and on behalf of the minor named herein. I agree to indemnify and hold harmless the person or entities mentioned above from any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Waiver and Release.
I hereby authorize any licensed physician, emergency medical technician, hospital or other medical health care facility to treat the minor named herein for the purpose of attempting to treat or relieve any injury received by said minor. I authorize any such Medical Provider to perform all procedures deemed medically advisable in attempting to treat or relieve such injuries. I consent to the administration of anesthesia as deemed advisable. I realize and appreciate that there is a possibility of complications and unforeseen consequences of any medical treatment, and I assume any such risk for and on behalf of myself and said minor. I understand that attempts will be made to contact me in the most expeditious way possible. Permission is also granted to the representative of Northside to provide the needed emergency treatment to the child prior to his/her admission to a medical facility.
Date: June 9, 2023