Name *
Birthday *
I, the parent or legal guardian of child listed above, a minor, by submitting this health card #, hereby authorize and give permission to the physician or medical practitioner, selected by Mountainview Christian Reformed Church to hospitalize, secure proper treatment including but not limited to the prescription of medications, diagnostic studies, and any other medical procedure for my child as deemed necessary by the physician under the circumstances. It is understood that this authorization is given in advance of any specific medical treatment being needed, and is given to provide authority to the physician to render that care which in exercise of his or her best judgment is advisable.
Special medications and/or pertinent information: (i.e. learning challenges, disabilities)
I agree that photographs and/or videos may be taken of my child at Mountainview Christian Reformed Church programs and events, and may be used in the promotion of Mountainview Church. They may be published or used for any application in newspapers, videos, posters, slide presentations, FaceBook, YouTube, other social media and networking sites or otherwise displayed to the public—either in whole or in part by Mountainview Church.
I authorize the transportation of my child by a volunteer or staff person of Mountainview Christian Reformed Church, in a church member's vehicle, to activities I will be previously informed of and for which I will have given my express permission.
Release and Waiver of Liability *
I/We, the parent(s) or Guardian of the above mentioned child, in consideration of my/our child being permitted to enter the Mountainview Christian Reformed Church (hereafter Mountainview CRC) property, and being permitted to participate in Mountainview CRC activities and events, AGREE TO WAIVE, RELEASE, DISCHARGE AND COVENANTS NOT TO SUE, its employees, officers, directors, servants and agents from all liability to the child, to myself, or any personal representative of either, assigns, heirs, and next of kin, for any and all claims for damages, for death, personal injury or property damage, suffered by me or my child while participating in any Mountainview CRC event or activity. I/WE UNDERSTAND THAT THIS RELEASE AND WAIVER OF LIABILITY applies to any claims occurring from injury to person or property, whether caused by negligence of Mountainview CRC or otherwise. I/We acknowledge that the intent of this RELEASE AND WAIVER OF LIABILITY is to prevent Mountainview CRC from being held liable for injuries to person or property, and that selecting YES constitutes my/our agreement and the agreement of the child listed above, not to hold Mountainview CRC responsible for any damages, losses, injuries to person or property, as a result of any negligence or other wrongful conduct on the part of Mountainview CRC or on the part of other third parties. I/We ALSO AGREES TO INDEMNIFY AND HOLD HARMLESS Mountainview CRC from any loss, liability, damage, or cost that Mountainview CRC may incur due to the presence of myself or said child, upon Mountainview CRC premises or in any way using any of Mountainview CRC facilities or attending any events of Mountainview CRC, whether caused by negligence of Mountainview CRC or otherwise. FURTHER, I/WE EXPRESSLY AGREE THAT THIS RELEASE AND WAIVER OF LIABILITY is intended to be as broad and inclusive as is permitted by the law in the Province of Ontario. If any portion is held to be invalid, it is agreed that the balance shall continue in full legal force and effect. I/We further agree that this Release and Waiver of Liability shall be valid for the program season or year. I/We have read and voluntarily agree, and further acknowledge that no oral representations, statements, or inducements apart from the written agreement have been made.