Crooked Creek Baptist Church Permission Form
Holiday World trip, Tuesday, August 3, 2010
Starting time: 7:30 a.m.
Ending time 11:00 p.m.
I, _____________________________ am the parent or legal guardian of __________________________
born on ________________, 19___. I warrant that I possess all the rights, powers, and privileges of a
parent or legal guardian necessary to execute this document with binding legal effect.
As the parent or legal guardian of ____________________________, I certify and affirm that I have been
completely and thoroughly informed that as a child attending Holiday World, my child
will participate in certain activities which carry with them a degree of risk and danger. I acknowledge and
understand that Holiday World may offer other activities not listed above that present
similar risks or dangers to my child. I consent to my child’s participation in these activities. I acknowledge
and understand that this PARENTAL AUTHORIZATION, CONSENT AND RELEASE has the same
force and effect regardless of whether the activities engaged in are free or if a fee is charged. Further, I
personally assume, on my child’s behalf, all risk in connection with said activities for any harm, injury or
damages that may befall my child as a result of my child’s participation in the activities, whether foreseen
or unforeseen, and I still wish to allow my child to proceed with the activities.
In consideration of my child being allowed to participate in these activities and to use
Holiday World equipment and facilities, on behalf of my child, I hereby voluntarily
release, forever discharge, and agree to indemnify and hold harmless Crooked Creek Baptist Church,
from any and all claims, demands, or causes of action, which are in any way connected with my child’s
participation in these activities or use of Holiday World, equipment and facilities.
I understand that it is my obligation to inform the church of any and all health considerations or medical
conditions that would restrict my child’s participation in any and all activities while in the care of
Pastor Tom Bartley. Should the need for medical attention arise the church will attempt to
contact me as soon as practicable under the circumstances.
In cases of emergency, I further consent to the examination or treatment of my child by a physician duly
licensed to practice medicine in the United States of America or any health care professional duly licensed
to provide heath care serviced in the United States of America for medical care and services deemed
necessary by the doctor, its agents, servants, and employees. I give permission to the doctor or health care
professional to provide any and all medical care they deem, in their professional opinion, to be necessary. I
agree to pay for any and all medical expenses incurred as a result of the use of this consent.
I acknowledge by signing this document, that if anyone is hurt or property is damaged during my child’s
participation in these activities, I may be found by a court of law to have waived my right to maintain a
lawsuit against the church on the basis of any claim form which I have released them herein. I agree that if
any portion of this agreement is found to be void or unenforceable, the remaining portions remain in full
force and effect. I have fully informed myself to the contents of this PARENTAL AURTHORIZATION,
CONSENT AND RELEASE by reading it before I signed it.
______________________________________ ____________________________ _______________
Signature Printed Name Date
Contact Number in case of an emergency ______________________________________