Brinner: ENCOUNTER Night Series


  1. I, the lawful parent or guardian of (the “child”), give permission for my child to participate in the activity described on the reverse and release from all liability and indemnify the International Church of the Foursquare Gospel d/b/a Pine Valley Church, and its directors, officers, council, agents, representatives, volunteers, and employees (“Church”) from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any damage, injury or illness incurred or caused by my child while participating in or traveling to or from the activity, or otherwise in Church custody. I understand the risks in these activities, including the possibility of unforeseen hazards, serious injury or death. I certify my child is able to participate in the activity.

  2. I agree to instruct my child to cooperate with the Church and its representatives in charge of the activity and understand my child may be prohibited from participating and/or sent home for any failure to follow the rules established by the Church.

  3. I appoint Church representatives who are acting as leaders, or designated by such leaders, as my attorney in fact to act for me in my name and my behalf, in any way that I could act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity, related travel or while my child is in Church custody.

    1. To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency transportation, medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our medical attorney-in-fact shall deem necessary or appropriate for the best interest of the child.

    2. I understand the Church will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.

  4. My child is to be excluded from the following activities and/or from release to the following persons  


  5. I agree that the Church may use my child’s and/or my own name, voice, portrait, photograph or image for promotional, website, office or any other church related purposes. These may be used in any broadcast, telecast, digital or print medium, including video images, photographs, pictures or renderings, audio recordings, or other likenesses, in combination or alone.

I will notify the Church immediately of any change in the information presented and agree it is valid until revoked in writing by me. I have carefully read this statement, and my signature acknowledges that I fully understand the content and meaning.

Completed by Parent or Guardian

Child’s Full Name:   

Birth date:   

Parent / Guardian Name:   

Parent / Guardian Phone Number:   

Parent / Guardian (2) Name:  

Parent / Guardian (2) Phone Number:   

Leave this empty:

Pine Valley Church
Signature Certificate
Document name: Brinner: ENCOUNTER Night Series
Unique Document ID: 0e346beff207ab5cb4bc5df7bcf2bb65cadc9658
Timestamp Audit
2017-01-31 14:59:44 MDTBrinner: ENCOUNTER Night Series Uploaded by Carrie Van Hoesen - IP