Winter Retreat

Page

It’s coming soon! mark your calendars for February 3-5 2017 for our amazing winter Retreat.

we will meet up at spmb at 5:15 friday, and plan to be back at church around 230 sunday afternoon.  A cell phone will be available on the way home for the youth to call with a more specific time.

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 #: ______________________

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s