Fox Chapel Presbyterian Church
412-963-8243
Parent Permission Slip
The Event:
Date and Time:
Where:
Transportation:
In an effort
to provide the best care and precaution for your child, please take a moment to
fill out the legal and medical forms below.
Thank You!!
Child’s Name (please print): _______________________________________________________________
Parent’s/Guardian Name (please print):
___________________________________________
q My child’s “Medical Release Form” is
on file for June 1, 2008 to May 31, 2009.
If your form is not on file, one MUST accompany this form. Please call the church office if a form is
needed.
q
Please DO NOT use
photographs of this participant for church publicity including brochures and
website.
Agreement of Participation
I understand
I will be representing Fox Chapel Presbyterian Church as well as myself. I will conduct myself in strict observance of
the standards of behavior expected by the church.
Code of Behavior
1. Participants must stay for the entire
event unless accompanied by a parent or guardian.
2. No foul language, drugs, alcohol,
tobacco or weapons are permitted.
3. Participants must respect the rights
and property of others.
4. Participants and parents/guardians
are responsible for any and all damages caused by the participant.
5. Failure to abide by code may result
in participant removal, by parent, from the event.
Assumption of Risk
As a
participant in this activity, I understand I may be exposed to risks to my
person and possessions which may result in physical injury, sickness or death,
or damage to my property. I understand
Fox Chapel Presbyterian Church may use the facilities and services provided by
third parties which are out of the control of the church. I freely and voluntarily accept and assume
all such risks, dangers and hazards and understand that Fox Chapel Presbyterian
Church , despite its efforts, may not be able to ensure my complete safety at
all time.
Liability Waiver
I release
and hold harmless Fox Chapel Presbyterian Church, its employees and agents from
any and all liability for any loss, damage, injury or expense that I may suffer
as a result of my participation in this activity, including but not limited to,
accidents, acts of God, sickness and transportation. I understand this agreement cannot be
modified except in writing by Fox Chapel Presbyterian Church and that no oral
modification shall be valid.
I have read this document carefully
and I acknowledge my responsibilities and the effect of this liability waiver.
_______________________________________ ______________________________________
Name of Participant – please print Signature
of Participant
If the above named person is not of
legal age, the following also must be completed.
I,
___________________________________, parent/guardian of
___________________________________
Parent/Guardian’s
Name – please print
Child’s name – please print
(the
“Minor”) hereby, on behalf of the Minor and his/her heirs, executors,
successors and assigns, agree to terms of the foregoing “Parent Permission Slip”.
_______________________________________ ______________________________________
Parent/Guardian Signature Relationship