RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
Please read the release and fill out the following form in order for your child to participate in our Summer Camp.
Functions and Activities
It is my understanding that participating in the programs and recreational and other activities of Christ Church Carpinteria’s Youth Ministry is a privilege. Prior to my child’s participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity related accidents, physical injury due to transportation related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.
Release of Liability
By signing this Permission/Waiver Form, I expressly warrant that my child named below is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me at this time. I further release Christ Church Carpinteria and its officers, employees, volunteers, and agents (hereinafter referred to as "Releasees") from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against Christ Church Carpinteria or its Releasees. I further agree to indemnify and hold harmless Christ Church Carpinteria and its Releasees from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities. I further hereby agree to indemnify and save and hold harmless the Releasees from any loss, liability, damage or costs they may incur due to the Participant taking part in the Event, whether caused by the negligence of any or all of the Releasees, or otherwise.
First Aid and Emergency Medical Treatment
In case of an emergency involving the Participant, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge of the Event to secure proper treatment, including hospitalization, anesthesia, or surgery for the Participant. Medical providers are authorized to disclose protected health information to the adult in charge of the Event, Event staff, and/ or any physician or health care provider involved in providing medical care to the Participant. Protected Health Information/ Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation for the Participant, follow-up and communication with the Participant’s parents or guardian, and/ or determination of the Participant’s ability to continue in the program activities.
By signing and typing my full name below, I am confirming that I am the participant's Parent/Legal Guardian and that I have read, understand, and agree to the Release.