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TLC
Church Camp Liability & Waiver Form
Child’s Name: _________________________________________________________
Parents Name: _________________________________________________________
Home #: ____________________________
Cell # __________________
Address:
____________________________________________________________
Does this child have any present injuries or limitations, allergies,
history of respiratory illness, or any other significant medical
conditions?
()Yes ()No
If yes, please state conditions:
____________________________________________
Please Read the following
information Carefully; Release must be Signed by parent
or legal guardian for children to participate in any TLC Church Event,
Activities or Ministry.
EMERGENCY AUTHORIZATION/CONTACT: I the undersigned, parent or legal guardians of the participant,
a minor, hereby authorize the TLC Staff, and Assistants or members
acting in the capacity of activity supervisors, as my Agent, to consent
to medical, surgical, or dental examination or treatment. In case of an
emergency, I hereby authorize treatment, and/or care at any hospital.
If there is an emergency and I cannot be reached please contact the
following emergency contact person, who is hereby authorized to act on
my behalf:
Emergency Contacts Full
Name: _____________________________________________
Phone #_______________________________
Cell # ______________________
Address: _____________________________________________________________
WAIVER OF
LIABILITY AND DISCLAIMER:
I, the parent or guardian of the above named individual acknowledges
that participation in the physical events of many ministries’ at TLC
Church may necessarily involve risks of injury. I further
acknowledge that the programs of TLC Church are primarily administered
by parents who volunteer their time rather than paid professionals.
In consideration for accepting the participation / registration of the
above named individual and permitting the voluntary participation of
said individual in our programs, I hereby release, discharge, and hold
harmless Towne Lake Community Church and its employees, volunteers and
other representatives from any claims arising out of or relating to any
physical injury that may result to said individual while participating
in the TLC sponsored event, including any physical injury by the
negligence of any volunteer while performing his/her duties during
sponsored activity.
TLC Pickup Regulations:
All children must be picked at 4:00pm promptly unless otherwise signed
up to participate in the after camp program at which time all children
must be picked up at 5:00pm promptly or be charged a $5 late fee for
every 5 minutes following the pickup deadline. These late fees will be
due at the time of pickup on that day. Children who are not picked up by
5:30pm and the Director has not been contacted of an emergency they will
be picked up by the Cherokee County Sheriffs Department due to safety
reasons.
Permission Statement (Photography):
I, the parent or guardian of the above named individual release and give
my permission to use my child’s photograph on the Church’s Website, in
Advertisements or Promotions regarding TLC Church and it’s ministries.
Signature or Parent or Guardian ___________________________ Date:
____________
TLC Representative: ___________________________________ Title:
_____________
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