2018-2019 Parental Activity Permission, Release and Power of Attorney

  1. I, the lawful parent or guardian of   , give permission for my child to participate in activities that occur during the 2018-2019 school year and release from all liability and indemnify Pine Valley Church of the Foursquare and its directors, staff, leaders, and volunteers from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising from 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 activities. 
  2. I agree to instruct my child to cooperate with the church leadership 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.
  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 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 camp leadership 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   (if left blank, no activities or persons are excluded). 
  5. I agree that the church leadership may use my child’s and/or my own name, voice, portrait, photograph or image for promotional, website, office or any youth program related purposes. These may be used for social media posts, videos, photos or other likenesses. 

I will notify the church leadership immediately of any change in the information presented and agree it is valid until revoked in writing or until the end of the 2018-2019 school year. 

Parent/Legal Guardian’s Signature Required


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Pine Valley Church https://pinevalleychurch.org
Signature Certificate
Document name: 2018-2019 Parental Activity Permission, Release and Power of Attorney
Unique Document ID: 55f07fbc99891842b2499d8169ec627aff1d48b5
Timestamp Audit
July 30, 2018 3:55 pm MST2018-2019 Parental Activity Permission, Release and Power of Attorney Uploaded by Carrie Van Hoesen - carrie@pinevalleychurch.org IP