Activity: Yakima River Float     Date(s): 7/12/16    Location: Central Assembly of God         Time: 10am                                                                           *Please send your student with their own flotation device/tube (life jacket if parent prefers) and a packed lunch to eat while floating

Emergency Contact Numbers:                Central Assembly of God: (509) 457-5144          Pastor Taylor's Cell: (509) 895-9063  

Activity Permission/ Waiver Form

Central Assembly of God (Activity Permission/Waiver Form) Please complete a separate form for each student
Yakima River Float
Date: 7/12/16
Student Name *
Student Name
Parent(s) / Guardian(s) Name *
Parent(s) / Guardian(s) Name
Address *
Cell Phone *
Cell Phone
Home/ Work
Home/ Work
Emergency Contact *
Emergency Contact
Emergency Contact Number *
Emergency Contact Number
At a leader's discretion, may a dose any of the following over-the-counter medications be administered? (Please Check applicable medications.) *
Permission *
I give my permission for my student, (Please Fill in Student's Name In the Box Provided Below), to attend the above activity with Central Assembly of God.
Waiver and Consent to Medical Treatment
I, the undersigned parent/legal guardian of the named student, do hereby grant my permission and consent for said student to receive emergency medical care if: 1) Such care is deemed necessary by the adult supervisor having custody of my student. 2) The proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my personal consent would reasonably jeopardize the life, health, or well being of the student affected. 3) I cannot be personally contacted. I also agree to pay all fees and costs arising from this action to obtain medical treatment.
Medical Insurance Provider
Mailing Address of Insurance
Group Insurance Number
Policy Number
Release of Liability
By signing this permission/waiver form, I expressly warrant that the student named above is capable of withstanding the physical demands of activities discussed above. I also expressly assume all risks of the student's or my participating in the activities, whether such risks are known or unknown to me at this time. I further release Central Assembly of God and its minister, leaders, employees, volunteers or agents. I further agree to indemnify and hold harmless Central Assembly of God and its ministers, leaders, employees, volunteers or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my student during such activities.
On occasion, Central Assembly of God takes photographs or makes audio or video tape recording of students and/or adults involved in activities. Such photographs or video records may be used by staff and participants to remember the activities or participants. In addition, such photographs and audio/visual recordings may be used in Central Assembly of God publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our church may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the student named above to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape and audio recordings. Furthermore, I give permission for the student to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media.
Term Agreement *
By checking this box I further acknowledge that I have read the above permission/waiver form and am fully familiar with the contents.
Name of Parent or Guardian *
Name of Parent or Guardian
By filling in my name and today's date I further acknowledge that I have read the above permission/waiver form and am fully familiar with the contents.
Today's Date *
Today's Date
Please enter a password below. We will be contacting you to confirm this password providing consent of the listed student's parent or guardian.