Get Excited about a great winter retreat coming up! The purpose of the retreat is to take some time to focus on our faith in a setting filled with fun and friends. We believe it can be a great help in our walk with God to change up the setting occasionally and spend some time away from everyday life. We believe God has things to teach us this weekend, and are excited to have a blast together. All this packed in three excellent days of winter fun at Pembina Valley Bible Camp. There will be great games, sledding, yuumy food, hangout time, late night adventures, and all the great times you have come to expect at youth! Please sign up in the church lobby and fill out a release form that is on the website or from Dan’s office. thanks
RELEASE/PERMISSION FORM
copy and paste this file to a word processor on your computer to print it out. This needs to be completed by each person going on the retreat, along with their parent/guardian. If you don’t have a printer, get a copy from Dan as soon as possible.
SOUTH PARK MENNONITE BRETHREN CHURCH
GENERAL RELEASE AND HOLD HARMLESS AGREEMENT – MINOR (0303-02A)
I, __________________________, am the parent or legal guardian of _______________________ (the minor(s)), who desires to participate in various programs, events or activities (hereinafter collectively referred to as the “Activities”) operated or sponsored by South Park Mennonite Brethren Church (SPMB).
I understand and acknowledge that SPMB will not allow the minor to participate in the Activities without releasing and holding SPMB harmless from any liability arising out of participation in the activities. I understand there may be risks involved in the minor’s participation in the Activities and fully assume such risks on his or her behalf.
I REQUEST THAT SPMB ALLOW THE MINOR TO PARTICIPATE IN THE ACTIVITIES, AND IN CONSIDERATION THEREOF AGREE HEREBY TO RELEASE AND FOREVER DISCHARGE SPMB, ITS OFFICERS AND DIRECTORS, AND ITS EMPLOYEES, AGENTS, AND ANY PARTIES VOLUNTEERING ON BEHALF OF THE CHURCH FROM ALL ACTIONS, CAUSES OF ACTION, INJURIES, CLAIMS, DAMAGES, COSTS OR EXPENSES OF ANY KIND GROWING OUT OF OR RELATED TO ANY SUCH ACTIVITIES IN WHICH THE MINOR PARTICIPATES. I UNDERSTAND THAT THIS IS A FULL AND COMPLETE RELEASE OF ALL INJURIES AND DAMAGES WHICH I OR THE MINOR MAY SUSTAIN AS A RESULT OF HIS OR HER PARTICIPATION IN ANY OF THE ACTIVITIES, REGARDLESS OF THE SPECIFIC CAUSE THEREOF.
I further acknowledge and agree that I have given my consent for the minor to participate in the Activities and to remain in the custody of SPMB representatives while participating in the Activities. (SEE OVER…)
This agreement is binding on the minor’s heirs, successors, and personal representatives.
Dated: _____________________________
Signed: ____________________________
Parent/Legal Guardian
MEDICAL TREATMENT AUTHORIZATION
AND POWER OF ATTORNEY
In the event the minor suffers an injury or condition during his or her participation in the Activities, including transportation to and from the Activity, which may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me have been unsuccessful, I hereby appoint eligible members of the SPMB leadership team as my agent(s) to act for me and in my name (in any way I could act in person) to make any and all decisions for the minor concerning his or her personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate when the agent is first able to contact me.
Special medical allergies, chronic illness or other conditions:
________________________________________
________________________________________
________________________________________
Minor’s Name: ____________________________
Age: ____________________________________
Medical # (9 digit): ________________________
Doctor: __________________________________
Doctor’s Phone: ___________________________
Signature: ________________________________
Emergency Contact #: ______________________
