Cell Phone Number
Henderson- MIDDLE SCHOOL
Henderson- HIGH SCHOOL
I will attend the Insomnia meeting on the following date:
Thursday, October 24 @ 7:00 PM
Do you have health insurance?
The undersigned is the participant or the guardian of the participant whose name is listed below. The undersigned gives permission for the individual to participate in the activities outlined in this brochure. The undersigned recognizes that the activities involve the risk of injury to persons or property. Such injuries may include, but are not limited to cuts, contusions, bruises, sprains, fractures to or death of the child. The undersigned expressly assumes the risk of injury to, or death of this individual, as well as property damage as a result of the activities associated with this Central Christian Church sponsored event. In the event of a medical emergency, the staff of Central Christian Church, or its representative, is hereby authorized to obtain emergency medical care and treatment of the participant, including transportation to a licensed medical facility. The staff of Central Christian Church, or its representative, shall notify the undersigned immediately concerning any such emergency. All costs and expenses resulting from a medical emergency shall be borne exclusively by the undersigned. The undersigned agrees to indemnify and hold the staff of Central Christian Church, or its representative, harmless from any claims, suits, liabilities, or judgments. Settlements, damages, costs and expenses, including reasonable attorney’s fees resulting from the injury, death, or property damage suffered as a result of the below-described activities will be the responsibility of the undersigned. The undersigned understands that the participant whose name is below is responsible to know and abide by all Central Christian Church rules and regulations. It is also understood that the undersigned shall be responsible for any damages caused by the participant during this Central Christian Church sponsored event.
The undersigned also understands that the participant named below may be sent home from this event due to disciplinary reasons at the discretion of the Central Christian Church staff and at the expense of the undersigned.
The undersigned also gives consent to the use of any audio or visual record of the participant to be used, distributed, or displayed for event celebration and future promotion. This consent includes, but is not limited to photographs, video and audio recordings.
This waiver shall legally include the following entities: Central Christian Church as well as other organizations under contract with Central Christian Church regarding this event.
I have read and agree to the terms above.
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