Online Consent Form for Children and YOUTH

First, MI, Last




Medical History


Medical Contact Information

Drop a file here or click to upload Choose File
Maximum upload size: 10.49MB


I, the undersigned, having read and consent to the rules, guidelines, and releases specified below, give permission for my child to participate.

Release and Consent

I give my consent for the registrant to participate in Mission Center/cluster youth activities for 2012/2013. I understand I will occasionally be required to give specific permission for any activities that would be considered high risk or out of the ordinary.

Medical Treatment Consent

I, the parent, legal guardian, next of kin, or participant signing the reverse of this page, hereby authorizes any necessary medical treatment for the registrant/myself. I also guarantee payment of all charges incurred during this medical treatment.

Liability Release

The parent, legal guardian, next of kin, or participant signing the reverse of this page, acknowledges that even though every effort is made to provide a safe, accident-free environment, incidents may occur. In consideration for being accepted by the Community of Christ and the Lamoni Heartland Mission Center, for participation in the youth program, we (I), being 21 years of age or older, do for ourselves (myself) (and on behalf of my child-participant, if said child is not 21 years of age or older and any parent, legal guardian or next of kin who has not signed the reverse of this page) hereby release forever, discharge and agree to hold harmless the Community of Christ, including the Lamoni Heartland Mission Center, and the leaders, whether volunteer/agents or employees, thereof from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned and the child-participant on account of ordinary negligence while said child is participating in the Mission Center/cluster youth activities. In addition, the undersigned agrees to indemnify the Community of Christ and its agents and assigns against any claim arising out of said child’s participation in the Mission Center/cluster youth program. Furthermore, we (I) (and on behalf of our (my) child-participant, if under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreating and work activities involved therein. Further, authorization and permission is hereby given to said organization to furnish any necessary transportation, food and lodging for this participant. The undersigned further agrees to hold harmless and indemnify said organization, its leaders, employees and agents, from any liability sustained by said organization as the result of negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

Photo Release

In consideration of the right of the applicant to participate in the Mission Center/cluster youth activities, I give consent to and authorize the taking of photographs or videotapes in which the applicant may appear, waive all right of privacy in and to any said photographs or videotapes; and authorize the Community of Christ, its successors, heirs, legal representatives, assigns and agents to use and reproduce my name, voice and/or likeness (photographic, illustrative, audio or video tape, film, electronic and/or digital image), and circulate and use the same for any and all official resource, use or purpose including but not limited to print, film, or electronic media and reproduction or digital representation of every description on the internet/world wide web.

Register your child one time for the whole school year.   Thanks!

Related Posts