(Please list someone other than the parents/guardians listed above.)
By signing below, I verify that the information provided is accurate and up to date. I grant permission for my child to participate in the W.A.S.P. program at Inola Christian Church.
I, the parent/legal guardian of the registrant(s) certify that he/she has my full approval to participate in this activity. The child identified on this form understands that he/she is expected to abide by the ICC rules and guidelines for this entire trip, and that they are directly responsible to the ICC leaders in charge while on campus or in any ICC approved activities and functions. All attendees are required to abide by the rules set forth by ICC and be directly responsible to ICC. Further, I do authorize approved leaders in the church of the activities, or an ICC staff member to take the participant to a doctor or hospital if I cannot be reached by the phone number provided. I hereby authorize the adults attending ICC to give any necessary over the counter and/or prescription medicine to my child. I also authorize medical treatment, including but not limited to injection, anesthesia, or surgery for my child, and I hereby assume financial responsibility for all expenses incurred for such treatment and, if necessary, all expenses to return the participant home. ICC assumes responsibility for discipline at the activity and, if necessary, may require a participant to leave. In such instance, I will assume full responsibility for returning the participant home. Further, I hereby release, discharge, agree to indemnity and hold harmless (a) ICC and its directors, officers, employees, event directors, agents and all other persons or entities acting on their behalf (the “Covered Parties”) and (b) the lessor/owner of properties on which the activities are held, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the participant, the undersigned, and/or any member of the participant’s family by reason of participating in any activities associated with events whether or not such claims, actions, demands, liability, costs or expenses are caused by the negligence or omission of any of the covered parties.
Physician & Insurance Information
Consent for Emergency Treatment
In the event of a medical emergency, I understand that every effort will be made to contact the parents, legal guardians, or the emergency contact listed above.
If a parent, guardian, or emergency contact cannot be reached, I hereby give my consent and permission to the W.A.S.P. leaders, volunteers, and staff at Inola Christian Church to secure necessary medical treatment for my child. This includes, but is not limited to, administering first aid, performing CPR, calling an ambulance, arranging for transportation to a hospital or medical facility, and authorizing life-saving care or emergency procedures as recommended by medical professionals.
I release Inola Christian Church, its staff, and volunteers from all liability, and I understand that I am responsible for all medical expenses incurred in the event of an emergency involving my child.
