Child's Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent or Guardian Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

LIABILITY WAIVER STATEMENT: *

I, agree to hold Cross Community Church and its agents and employees harmless form any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to myself or any family member present, even injury resulting in death, which may now exist or which may arise in the future in connection with the activity or participation in any other associated activities. I acknowledge that participation in the activity involves risk to the participant, and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the Cross Community activities the participant acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, by the sponsor or its agents, employees, volunteers, or any other representatives. Furthermore, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. Please type your name below to accept this agreement:

First Name

Last Name

Photo Waiver: My child(ren) may be photographed during VBS at Cross Community. *

Yes

No