ELIZABETH LAKE CHURCH OF CHRIST YOUTH GROUP WAIVER FORM

I, __________________, the legal guardian of _________________ acknowledge(Parent/Guardian)(Partici

pant)that he/she has my permission to take part in all youth related activities as an informed and completely
voluntary act. I understand that he/she will be required to make choices and keep a schedule, and he/she
may not be under direct adultsupervision at all times. I authorize the Elizabeth Lake Church of Christ
Youth Leaders and/or it’s representatives to care for the administration of general first aid for minor injuries
and further authorize them to summon any and all professional emergency personnel to attend, transport
and treat my child in the event of a life threatening injury. I agree to assume all risk associated with his/her
participationin such events and agree to release and hold unaccountable any staff, assistants of The Eliza-
beth Lake Church of Christ (paid or volunteer) and Michael Barber from all claims, suits, costs and actions
of any kind, arising from their exercise of power granted by this authorization.

Dated :
In the State of Michigan, this _______ day of ______________, 2008.

____________________ Participant Signature

____________________ Parent/Guardian Signature
____________________ Witness
If you are less than 18 years, a Parent or Guardian’s signature is required.

Health Number ____________________

Emergency Contact ______________________
Relationship________________Phone (home) ________________ (work) _________________
Medical Information :

List name(s) and dosage(s) of any medications participantswill be required to

take during this time. Also indicate any medical or healthconditions that may be
a concern during these activities._______________________________________
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