Permission to Participate

Event here:______________________________________________

Date here:_______________________________________________

Name of Student Particpiating _______________________________

 Date of Birth _____________________________________________

Parent's  Name __________________________________________

Address ________________________________________________

City/Zip _________________________________________________

Daytime Phone __________________________________________

Cell Phone _______________________________________________

Evening Phone ___________________________________________

Medical Problems/Medications for each family member

Alternate Emergency Contact ________________________________

Daytime Phone ____________________________________________                              

Cell Phone  ______________________________________________
 
Activity Permission and Authorization to Consent to Treatment of Child
 
As the parent or legal guardian of the child named above, I authorize participation of my child in the activity listed above.  I authorize staff members and authorized volunteers to consent to any examination, anesthetic, medical or surgical treatment and hospital care for my child which is deemed advisable by a physician or surgeon licensed under the provision of the Medical Practice Act. It is understood that this authorization is given in advance of an specific need.  I assume all financial responsibility for any emergency transportation, treatment or hospitalization of the above mentioned minor.
                                                                                                                                                                                                                                                                      
                                                                                                                                                                                                                                                                        Initials ____________
 
I also fully understand that any travel, activity or outdoor pursuit have inherent dangers that no amount of care, caution, instruction or expertise can eliminate. Mindful of these conditions, I  FOREVER RELEASE AND DISCHARGE Maranatha Chapel and Maranatha Schools, it's personnel and volunteers for any and all liabilities, claims, demands or causes of action that I may hereafter have for any injuries or damages arising out  of my child's  participation on the above referenced activity.   I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISK OF DEATH, PERSONAL INJURY OR PROPERTY DAMAGE SUSTAINED BY MY CHILD WHILE PARTICIPATING IN THE ABOVE REFERENCED ACTIVITY AND AGREE FOR MYSELF, MY CHILD AND MY HEIRS, REPRESENTATIVES AND ASSIGNS TO INDEMNIFY AND HOLD HARMLESS Maranatha Chapel for any and all losses, claims actions, or proceedings of any kind which may be initiated by myself, my child or any other person or organization, including demands for damages, judgments, costs, losses of services, or expenses, arising from the activities contemplated by this agreement, including but not limited to reasonable attorney fees incurred by Maranatha Chapel herein.                                                                                                                                                                                                                                                                                                                                                                       

Initials ___________
 
On behalf of the above person, who is a minor, I agree for said minor and for myself to be bound by all terms and conditions of the foregoing agreement, including to INDEMNIFY AND HOLD HARMLESS MARANATHA CHAPEL as set forth above.
 
 
 
X_______________________________________________________________

Signature of Parent, Guardian or Responsible Party
(if Participant is under 18 years of age)
 
Today's Date_________/________/_______   
                                               
THIS PERMISSION SLIP MUST BE SIGNED, INITIALED  AND PAYMENT
ATTACHED TO COMPLETE REGISTRATION