Child's Name *

First Name

Last Name

Child's T-Shirt Size *

Child's T-shirt Size:

Youth XS

Youth S

Youth M

Youth L

Adult S

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

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Physician's Phone Number *

(###)

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Parent/Guardian Emergency Contact Information: *

First Name

Last Name

Emergency Contact's Phone Number *

(###)

###

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Alternate Emergency Contact Person's Name (in the event that the person listed above cannot be reached) *

First Name

Last Name

Alternate Emergency Contact's Phone Number *

(###)

###

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Palmetto Presbyterian Church requests permission to use photography and/or video of your child/children for the purposes of public relations, marketing, and development. This release includes use of any such images within newsletters, newspaper, Palmetto Presbyterian Church's website, video or TV, but any such use of your child's image will not include the child's name. I hereby give consent to Palmetto Presbyterian Church, its assigns, licenses, and legal representatives the right to use my child/children's image or photograph in all forms and media for marketing, development, or any other lawful purpose. *

Yes

No

have been informed of the above activity sponsored by Palmetto Presbyterian Church and hereby give my permission for the minor child to participate in this activity. *

CONSENT, RELEASE, and WAIVER: • I understand that the activity may involve participation in physical activity for the event, and that the possibility of harm does exit. I, personally and on behalf of the Participant, further agree and do hereby release and forever discharge and hold harmless Palmetto Presbyterian Church, its officers, directors, coordinators, and adult advisors from any and all liability, claims and demands of whatever kind or nature, in law or in which may arise or may hereafter arise from the Participant’s participation in the activity. • I understand and agree that this Release discharges Palmetto Presbyterian Church from any liability or claim that I or Participant may have against Palmetto Presbyterian Church with respect to injury or illness that may result from the Participant’s participation in the activity with Palmetto Presbyterian Church. • I do consent to emergency medical treatment if deemed necessary for my minor child before and while all reasonable efforts are made to contact me or the emergency contact. • I give my permission to the medical personnel on site to treat my minor child as he or she deems medically necessary. I further understand that the medical personnel will take all reasonable safety precautions during their care. • I understand, as a parent or legal guardian, I am responsible for the health care expenses incurred on behalf of my minor child. I, the parent or legal guardian of the above named child/children, recognize and acknowledge the inherent risk of playground and classroom play as anticipated and/or any or all other activities, whether planned or unplanned, which may take place during the activity/program, including but not limited to, the inherent risk of manual and physical activity. In consideration of the benefits of my child/children's inclusion in the above, I on behalf of myself, my child/children, my family and my spouse, if any, agree to assume the risk, hold harmless, release and indemnify Palmetto Presbyterian Church and any of their staff, agents and/or employees as well as volunteer parents/guardians, and/or chaperones acting on behalf of Palmetto Presbyterian Church for the activity/program from any and all claims, demands and/or causes of action arising from any unintentional act of Palmetto Presbyterian Church or such volunteer parents/guardians and/or chaperones and from intentional or unintentional acts of others causing damages, death, injury, loss, accident, delay, irregularity, or expense to person or property incurred at any time during the above activity. I also agree to assume full responsibility for and to indemnify, hold harmless and release Palmetto Presbyterian Church from any financial obligations or liabilities that I or my child/children may incur or any damage or injury to the person or property of others caused while participating in any Palmetto Presbyterian Church activity.  Please remember your child's transportation to and from events, with the driver of your choosing, is at your own risk.  By signing below, I knowingly agree to the Release, Assumption of Risk, Hold Harmless and Indemnity Agreement (for programs/activities, before and after event programs, playground and classroom play).  Signature of Parent/Guardian

First Name

Last Name

Date *

MM

DD

YYYY