Chosen- Release of Liability Waiver- VBS

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All information provided in this document is used for insurance purposes only. No information is shared to any entity in any form. In exchange for participation in the VBS event organized by Chosen, Inc, I agree for myself and (if applicable) for the members of my family, to the following conditions:

Email *

#1 *

I represent that I am the parent or legal guardian of the participant named below, or I have obtained permission from the parent/guardian of the participant named below to execute this agreement on their behalf. I further represent that the participants are healthy and physically able to participate in any and all undertaken activities.

Required

#2- Emergency *

In the event of any illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical, dental, allergic, or surgical diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child when I am not immediately available for consultation. I understand that every effort will be made to contact me as the guardian of my child in case of emergency.

Required

#3 Child Conduct *

I fully understand that for the safety of the children and volunteers/staff, certain rules and regulations will be upheld. By signing this document, I agree that my child must accept and obey all rules and requirements governing conduct during VBS and VBS related trips or activities. It is understood that VBS may disallow any child further participation in VBS and VBS related activities if it is determined that they are in violation of these standards.

Required

#4 Liability Release

I, the undersigned, release and discharge Epikos Church and/or Chosen, Inc. its officers, employees, agents, and servants, from all liability for injuries to my child arising out of or in connection with VBS or VBS related activities or trips. I further understand that Epikos Church and/or Chosen, Inc. its officers, employees, agents, and servants shall not be held liable for youth who, against the advising of counselors or recognized parental/youth volunteers, leave the grounds without appropriate supervision or permission.

#5 Photo/Video opt OUT

We often take pictures at our events to help preserve memories and foster community. We assume the right to use some pictures to help promote an awareness of what goes on in our ministries on our website(s), social media venues (Twitter, Google+, Facebook, Instagram, YouTube, and venues of applicable likeness) and in our publications (newsletters, ministries updates, and promotions). Please check here if you do NOT want images of your children used in these ways (no revealing photos of any current foster children will be used in any way).

Parent/Caregiver first name *

Parent/Caregiver Last Name *

Preferred Email *

Address *

City *

State *

Zip Code *

Emergency Phone # *

Child #1 Name *

Child #1 Date of Birth *

YYYY

Child 2 Name

Child 2 Date of Birth

YYYY

Child 3 Name

Child 3 Date of Birth

YYYY

Child 4 Name

Child 4 Date of Birth

YYYY

By initialing below and submitting this form you agree to all conditions set in this document above.
*

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