Parent/Guardian #1 Information
Parent/Guardian #2 Information
(In case of medical emergency, where parents cannot be reached immediately.)
Medical/Behavioral Issues or Physical Restrictions
Note: Cornerstone does not stock or dispense ANY medication. Information on medication will be used only in the event of an emergency. It is the responsibility of parents/guardians to make sure Cornerstone is updated on changes to their child's medications.
Authorization of Participation
I understand that by entering my name in the box at the end of this form I am providing my digital signature and, hereby authorize my child to do the following:
a) participate in Cornerstone's programs and activities
b) use Cornerstone transportation (From school to Cornerstone, Field trips, etc.)
c) be given medical treatment in the event 911 is called, and a parent/guardian cannot be reached
d) be held accontable to the Cornerstone commitment
Permission for Transportation
Periodically, Cornerstone Community Ministries produces newspaper ads, brochures, web pages, newsletters, etc. In the production of these items, we like to include photos of youth who attend our youth center. (We do not use names of youth in our captions.) We are asking for your approval to use photos of your child/children ahead of time. If you are willing to allow us to use your child's photo in these types of publications or promotions, please indicate that approval by checking the appropriate box below.
If you have any questions, please don't hesitate to call us. Thank you very much.
SkatePark and Rock Wall Waiver and Release of Liability
1. I acknowledge that the risk of serious injury, including permanent disability and/or death from the activities involved with participating in the SkatePark and/or Rock Wall are significant, and that these risks may result not only from my own actions, inactions or negligence, but also the actions, inactions or negligence of others, or the training involved, or the condition of the premises and any of the equipment used; and,
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
I willingly agree to comply with the stated and customary terms and conditions for participation. If however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation, and bring such hazards to the attention of the nearest official immediately.
I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Cornerstone Community Ministries, Inc., their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, I FULLY UNDERSTAND ITS TERMS. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Parent Signature and Permission
