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GRACE CHURCH – SAN ANTONIOYOUTH ACTIVITIES PERMISSION & LIABILITY INFORMATION FORMSPRING 2015 – SPRING 2016Participant Name:_____________________________________________________ Grade: ___________ Birth date (m/d/yr): ___________________________Parent Name(s):________________________________________________ Work Phone: ________________________Cell Phone:_________________________ ________________________________________________ Work Phone: ________________________Cell Phone:_________________________ Insurance Company: __________________________________ Identification #: __________________________Group #: _______________________________ Ins. Phone: __________________________Allergies (medicine/other): __________________________________________________________________________I. PERMISSION TO PARTICIPATE - I hereby grant my permission for my child to attend the Grace Church event(s) listed below (see attached flyers for more information). I (we) understand that such an activity involves some risk of illness or injury to the participant. In case of emergency, I hereby grant permission to secure any and all medical care including (but not limited to) hospitalization, administer treatment, order anesthesia, medication or surgery for my child as named below in the event I cannot be reached. I understand every effort will be made to notify me. II. LIABILITY RELEASE – In consideration for the opportunity to participate in church-related activities (which may include, without limitation, any trips, events, indoor and outdoor games or other activities), for the 2013-2014 church year, the undersigned Adult Participant, Parent or Legal Guardian does, for ourselves or on behalf of the Minor participant designated below: hereby release, forever discharge and hold harmless Grace Episcopal Church, San Antonio, Texas, its Bishop Committee, clergy, employees, agents and authorized representatives (collectively, the “Church”), from and against any and all liability, claims and demands for personal injury, sickness and/or death, as well as any property damage and expenses, of any nature whatsoever, which may be incurred by the undersigned or any of them while participating in any Activities; authorize the Church to furnish any transportation, food and/or lodging deemed reasonably necessary or advisable by the Church to allow the undersigned or any of them to participate in said event(s), and that the undersigned Adult shall pay to the Church all costs incurred by the Church and charged to Adult therefore, including any costs incurred by the Church or by any of the undersigned in the event the Church requires any of the undersigned to return home for any reason, including but not limited to medical or disciplinary reasons; adhere to, and cause the minor participant to adhere to, the following rules of conduct, and, by their signatures below, each of the undersigned does hereby represent that each has read/been apprised of said rules, and shall abide by same: Remain with the group, and reasonably endeavor to participate in all activities, for the duration of the Activities; Not to bring or use tobacco products, alcohol, illegal drugs, weapons, fireworks, pornographic materials or explosives; Not to engage in sexual misconduct, honor all curfew arrangements, and respect all other participants and accompanying leaders; Hereby hold harmless and indemnify the Church for any damages and/or liability sustained by the Church as a result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. III. MISCELLANEOUS CONSENTS - By voluntarily allowing my children to participate in a Grace Church event, group or activity, I, the participant's guardian, am giving permission for the participant's photo and video to be used in Grace publications, print and online, unless Grace is given written request to the contrary. I give my permission for the undersigned Minor to view PG-13 motion pictures unless otherwise given in writing to Grace. If any condition arises that alters the information on this annual form, I understand that it is my responsibility to notify Grace Church in writing of the changes prior to the next activity. Currently, however, the above information is true and correct. ____________________________ _____________________________________ ___________________ Name of Participant Participant’s Signature Date ____________________________ _____________________________________ ___________________ Parent or Guardian Name Parent/Guardian’s Signature Date ................
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