Event Registration

Parent or Guardian Consent and Liability Release:
I, the undersigned parent or legal guardian of the above mentioned minor, do hereby authorize any leaders from Whittier Area Community Church (hereinafter WACC) to authorize and consent any examination, anesthetic, medical or surgical diagnosis rendered under the general or specific supervision of any member of the medical or emergency room staff licensed under the provisions of the Medicine Practice Act, or a dentist licensed under the provisions of the Dental Practices Act and on the staff of any acute general hospital or emergency facility holding a current license from the Dept. of Health. It is understood and agreed that WACC’s insurance is only secondary insurance and that the signer’s medical insurance will be billed for any and all medical charges in the case of illness or injury resulting from participation in any way with an activity sponsored by WACC. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required and is given to provide authority and power to render care and/or treatment to the patient regardless if the undersigned is able to be contacted. Further, the undersigned agrees that WACC, its volunteers, employees, and affiliates shall be held harmless from any and all liability for damages to person or property to the participant’s above mentioned that may arise out of, en route to and from, in residence, or as a result of, any involvement or participation in activities sponsored by WACC. In exchange for the privilege of participation in activities sponsored by WACC, I hereby indemnify and hold harmless WACC, the staff, employees, and volunteers of WACC from any and all liability and expenses incurred as a result of participation. 
The health information on this form will only be shared, as needed, with group leaders and medical professionals to safeguard and support the child in an emergency situation. This information will not be publicly disseminated or released to any outside organization.

Photo Release: I will allow my child(ren’s) photograph to be published on the WACC website and/or to be used by WACC for promotional purposes.  Photographs may be published in the form of print, electronic, video or photographic materials created for church use.