PERMISSION TO PARTICPATE AND MEDICAL RELEASE



Activity Participation Agreement

Bethel Church/Destiny Christian Center … Children’s Ministries

Nitro Kid’s Conference

▪ Activity: A day where kids can experience God in a way that they'll never forget at Overlake Christian Church in Redmond, WA.

▪ Date: Saturday, March 22nd

▪ Time: Drop off at 7:15am @ Bethel Church, leaving at 7:30am. Pick up at 6:00pm @ Bethel Church

▪ Group: 2nd-6th Grade

▪ Cost: $60

▪ Registration DEADLINE: Sunday, March 9th

▪ Additional Info: Eat breakfast before arriving. We will provide a snack for the ride up and lunch. No cell phones or music playing devices are allowed.

Participant Information

Name of participant: ____________________________________________ Grade: ________ Birthdate: ____________________

Name of parent/guardians: ___________________________________________________________________________________

Address: _____________________________________________________ Cell Phone: ________________________________

Home Phone: _____________________ Email Address:__________________________________________________________

Name of emergency contact: _________________________________________________________________________________

Telephone (day):_________________________________ Telephone (evening): ______________________________________

List allergies or medical conditions: ____________________________________________________________________________

Is the sponsor (Bethel Church) authorized to approve medical treatment? □ Yes □ No

Is participant covered by personal/family medical insurance? □ Yes □ No

If yes, name of insurer: _______________________________________________________________________________________

Policy or group number: _____________________________________________________________________________________

Participation Agreement

I acknowledge that participation in this activity described above involves risk to the Participant (and to the Participant’s parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above, the participant (and to the Participant’s parents or guardians, if Participant is a minor), acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the Participant that is authorized by Bethel Church or its agents, employees, volunteers, or any other representatives (collectively referred to as Bethel Church). Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless Bethel Church for any injury arising directly or indirectly out of the described Activity or transportation to and from the activity, whether such injury arises out of the negligence of Bethel Church, the Participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and Bethel Church cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.

Parent/Guardian Signature: ________________________________________________________ Date: ______________

NOTE: The information given on this form will be kept strictly confidential. This form is valid only for the stated activity and date. This form will not be accepted if changed in any way or without parent / guardian signature. Students will not be allowed to participate in an activity in any way without this form. If you have questions regarding this form please contact Pastor Jeremy Scott at (360) 748-0119.

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Date paid

Amt paid

Type of payment:

CK CA OL

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h5CJh1jh55?CJOJPJQJU[pic]^Jmh/Destiny Christian Center… Children’s Ministries

132 Kirkland Rd. Chehalis, WA 98532 PH: 360.748.0119 FAX: 360.740.0246 bethel-

Kyle Rasmussen, Lead Pastor Jeremy & Amy Scott, Children’s Pastors

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