13720 SW Highway 126 Powell Butte, OR 97753 541-548-3066

Consent and Release Form

I the undersigned parent or guardian, hereby consent to my child, _____________________________, participating in 

(Fill In Specific Event and Date)     

This event is sponsored by the Powell Butte Christian Church.  I certify that my child is able to participate in this activity including van (or private vehicle) rides to and from the activities.  If my child has a medical condition which may be relevant to a physician in the event of an emergency, I have listed them below.  In the event an emergency occurs, I may be reached at the telephone number listed below.  If I cannot be reached, I hereby authorize Chris Blair, Glenn Bartnik, or any other adult sponsor, to make emergency medical decisions for my child.  If there are any activities I do not want my child to be involved in, I have listed them below and I hereby acknowlege and approve of my child's involvement.

I UNDERSTAND AND HERBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITY/IES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO.  I do hereby agree to hold Powell Butte Christian Church and its agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities.  I expressly agree that this release, waiver and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Oregon and that if any portion thereof is held invalid it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.  This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT.  This is a legally binding agreement which I have read and understand.

____________________________    _______________

Parent or Guardian                               Date

_____________________ or_______________________

Emergency Contact Phone Numbers

Medical Insurance: Carrier:________________ ID#__________________  Group#_____

Medical Conditions: ______________________________________________________

I do not wish my child to participate in the following:

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