Youth Permission Form

Covenant Cedars Fall Retreat Registration Form

Questions? Contact , [email protected] (712)-359-7706 for additional information.

* Indicates required field

Student Name *

First

Last

Date of Birth *

Address *

Student Email Address *

Student Phone Number *

Student School and Grade *

T-Shirt Size *

Parents / Guardian *

Legal Relationship *

Father Mother Legal Guardian

Parent Email Address *

Parent Phone Numbers *

Alternate Emergency Contact *

Relationship *

Emergency Contact Phone Number *

Medical Insurance Carrier *

Policy Number *

Group Number *

Name of Insured Person *

Allergies *

Pre-Existing Medical Conditions *

Medications *

Other Medical Concerns *

Waiver, Release, and Assumption of Risk
I (We) acknowledge that my child's participation in Pomeroy Covenant's activities is voluntary and may require traveling or physical exertion. Such activities may include, but are not limited to: outings, athletic games, local excursions and meetings, and other activities. I (We) acknowledge that my child's participation in any Pomeroy Covenant youth activities presents risks that I or my child may suffer including, but not limited to, damage to personal property, financial damage, emotional injury, illness, bodily injury, or death. I (We) hereby assume those risks. And, in consideration of my child's being allowed to participate in Pomeroy Covenant's youth program activities, I (We) agree and take the following actions for me and my child.

I (We) waive, release, and discharge Pomeroy Covenant, its pastors, directors, members, employees, volunteers, representatives, subcontractors, and agents from any and all claims for: (A) Financial losses, including, (but not limited to) insurance deductibles and medical expenses, that we are parents or guardians must pay as a result of injury or illness arising out of activities sponsored by Pomeroy Covenant; (B) Damage, destruction, loss or theft of personal belongings of the minor participant or parents of the same; and (C) Any claims or liabilities that I (We) may assert as parents for loss of consortium, death, or personal injury, which arise out of or relate to my child's participation in Pomeroy Covenant's youth activities; and, to the extent allowable by law, all similar or identical claims that my child may assert. Notwithstanding any of the foregoing, Pomeroy Covenant is not released from any claims or liabilities that are caused solely by Pomeroy Covenant.

I (We) agree not to sue any of the persons or entities mentioned above for any of the claims or liabilities that I (we) have waived, release, or discharged herein.

I(We) indemnify and hold harmless the person or entities mentioned above for any claims made or liabilities assessed against them as a result of any inaccuracy on Registration form, including Basic Information, Health Insurance, Health History, Waiver, Release, and Assumption of Risk form.

I hereby execute this document for and on behalf of the minor named herein.

Parent(s)/Guardian *

Date *

Student *

Date *

Submit