Permission Slip & Waiver

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PERMISSION SLIP Event: Student Ministries Winter Retreat 2019 Dates: February 15-17 Event Contact: Patrick Rowland Participant Name: ​____________________________________ ​T-Shirt Size:​ ____________

WAIVER I/we give consent for the above named child to attend and participate in the above listed event. I/we waive and release any and all rights for damages I/we may have against College Park Church, Inc., ("College Park") its elders, employees and volunteers, for any injuries suffered by the child in connection with his/her participation in the above named event, except those that result from criminal acts or omissions or reckless endangerment. I attest and verify that my son/daughter is physically fit for the activities listed above and all other ordinary activities which might reasonably be associated with such an event. The undersigned does also hereby give permission for my (our) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in above named event.

MEDICAL CONSENT I/we grant a limited power of attorney to authorized representative of College Park Church and/or EVENT CONTACT ("Attorney-in-Fact"), in whose care the child has been entrusted, to consent to any emergency: 1) x-ray examination, 2) anesthetic, 3) medical, 4) surgical or 5) dental diagnosis and/or treatment, and for any emergency hospital care, to be rendered to child under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital for emergency care. I/We further authorize health care providers to rely on the Attorney in Fact’s decisions just as if I/we had made them myself/ourselves, and I/we hereby ratify and confirm all that the Attorney in fact shall do by virtue hereof. I/we hereby release and hold harmless any health care professional from and against any and all losses, damages and claims that I/we or our child may have by virtue of the health care professional treating our child in reasonable reliance upon this Consent. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for my (our) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in above named event or medically necessary vehicles. Parent/Guardian Name: ​____________________________________ Parent/Guardian Signature: ​____________________________________ **Participants who are over the age of 18 may sign the form themselves.