(If divorced or separated from the child's other parent, I am the
primary residential parent of the child, and have specific authority to give this consent.)
I give my permission for my child to attend and participate in the YOUTH GROUP WINTER RETREAT, which may include the following activities:
outdoor & indoor games.
I DO NOTÂ give permission for my child to participate in the following
I generally understand the nature of YOUTH GROUP WINTER RETREAT activities and accept the risks involved in those activities.
I release Lebanon Calvary Chapel from all claims, causes of action or damages which I or my child might have as a result of participating in the YOUTH GROUP WINTER RETREAT and I agree to save and hold Lebanon Calvary Chapel harmless from those claims, causes of action or damages.
I authorize Lebanon Calvary Chapel to be my child's agent for medical treatment purposes. I authorize Lebanon Calvary Chapel staff or leaders to obtain any medical advice or treatment reasonably necessary during my child's participation in the YOUTH GROUP WINTER RETREAT In the event of emergency, this authorization includes but is not limited to the expenses of any necessary ambulance, hospitalization, x-rays, anesthesiology and/or surgery.
I give my consent in advance of any specific diagnosis, treatment or hospital care required. I understand that if medical treatment is necessary for my child, Lebanon Calvary Chapel must rely on the advice of the physician involved, and on the exercise of the physician's best medical judgment.
I agree to pay all expenses incurred in providing medical treatment to my child under this agreement, and to reimburse Lebanon Calvary Chapel for any medical expenses paid.. I specifically save and hold Lebanon Calvary Chapel harmless from responsibility for those expenses.
I furnish the following information regarding my child:
Emergency Contact Information