To be completed by a parent or legal guardian
Please complete this form for each minor participating or volunteer serving or leading at Dream City Church ("Dream City Church" or "DCC") activities, events or trips occurring both on and off campus.
Name of minor:
Date of birth:
Name of School:
Minor's Phone: (Area) Phone number:
Mother’s full name:
Mother’s cell phone: (Area) Phone number:
Father’s full name:
Father’s cell phone: (Area) Phone number:
Legal Guardian (if applicable):
Guardian's cell phone: (Area) Phone number:
In the absence of parent or guardian, Dream City Church may contact:
Phone: (Area) Phone number:
Medical Phone number:
Is tetanus immunization current:
Are your child’s shots up to date?
Is there anything that will prevent or restrict child’s participation in any activity?
In the event of sickness, injury, accident or some other medical emergency, I (we) request that my (our) child receive any medical attention or treatment deemed necessary. Therefore, I (we) the parent(s)/guardian(s) give permission to hospitals, doctors, health care providers and/or any Dream City Church Leader to transport, admit for care and provide treatment for my (our) child. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify Dream City Church, DCC staff, DCC volunteer leaders and DCC Board of Directors.
I agree to pay for all medical expenses incurred as a result of the use of this consent.
I understand that it is my obligation to inform the management of Dream City Church of all health considerations or medical conditions that would restrict my child’s participation in all activities while at Dream City church or involving Dream City Church or its programs.
This permission will extend for one full years and will expire 12 months from the date given below, or if the minor reaches 18 years of age before the one-years is reached, or I (we) as parent(s) or legal guardian(s) revoke this medical release in writing.
Release of Liability and Indemnification:
I (we) agree that the minor referenced above may participate in various activities with Dream City Church. I (we) further understand that Dream City Church is a non-‐profit organization and agree to release Dream City Church of all liabilities the minor may suffer because of participating in various activities with Dream City Church. I (we) give permission for my (our) child to participate in Dream City Church activities/events occurring both on and off campus.
As a parent or legal guardian, I certify and affirm that I have been completely and thoroughly informed that as a minor attending Dream City Church, my child will participate in certain activities which carry with them a risk and danger.
Examples of risky and dangerous activities include, but are not limited to:
- Physical activities, both indoors and outdoors
- Sports, both informal and organized
- Use of recreational equipment
- Field trips, both on and off campus
- Travel by automobile
- Activities around water, including swimming, boating, baptism
- Hiking, camping
- Construction, and maintenance projects
I acknowledge and understand that Dream City Church may offer other activities not listed 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 CERTIFICATION, 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 because of my child’s participation I the activities, whether foreseen or unforeseen, and I sill wish to allow my child to proceed with the activities. I acknowledge and agree that Dream City Church shall not be held liable in any way for any occurrence resulting directly or indirectly from these activities that results in injury, death, or any other damages to my child, me, or my family, heirs, or assigns. In consideration of my child being allowed to participate in these activities, on behalf of my child, I hereby personally assume all risk in connection with said activities, for any harm, injury, or damage that may befall my child, me, or my family, heirs, or assigns while engaged in such activities.
EARLY RETURN HOME POLICY: Should it be necessary for my minor to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.
Release and Hold Harmless of Dream City Church:
I (we), individually and as next friend of the minor made the basis of this document, as the releasing party do hereby and forever release and hold harmless Dream City Church and its respective agents, volunteers, employees, attorneys, assigns, and all of their respective successors in interest from any and all claims I (we) could bring individually and as next friend of the minor related or incidental to the minor’s participation in all events and activities in any way associated with Dream City Church, either at its principal address or on trips, and whether caused by the sole, joint or contributory negligence of Dream City Church and resulting in damage to personal property, bodily injury, or death.
Release of Media Rights:
I give Dream City Church permission to publish in print, electronic, or video format the likeness or image of my child including audio recordings of my child. I release all claims against Dream City Church with respect to copyright ownership and publication including any claim for compensation related to the use of the materials.
Images, videos, and audio recordings of my child taken or recorded by Dream City Church can be used in print, broadcasting, and in other forms of advertising; brochures, newsletters, and other church publications on the Dream City Church website; in audiovisual presentations; and in other activities to promote Dream City Church and inform the public about Dream City Church without payment of feeds, royalties, or other remuneration.
When images are published, Dream City Church will take cautionary steps to provide minimum identifying information and will not use specific street or mailing addresses, e-mail addresses, or phone numbers.
Indemnification of Dream City Church:
I (we) HEREBY AGREES TO FULLY INDEMNIFY AND DEFEND DREAM CITY CHURCH AND ITS AGENTS, VOLUNTEERS, EMPLOYEES, ATTORNEYS, ASSIGNS, AND ALL OF ITS RESPECTIVE SUCCESSORS IN INTEREST AGAINST ANY AND ALL LIABILITY, CLAIMS, DEMANDS, OF ANY TYPE OR CHARACTER ALLEGED BY ANY PARTY INCLUDING BUT NOT LIMITED TO DAMAGES, LITIGATION EXPENSES, COURT COSTS, LOSSES, DEFENSE COSTS, AND ATTORNEY’S FEES FOR INJURY OR DEATH TO ANY PERSON, INCLUDING THE UNDERSIGNED OR THE MINOR MADE THE BASIS OF DOCUMENT, DIRECTLY OR INDIRECTLY ARISING OUT OF OR RELATED TO THE UNDERSIGNED’S OR THE MINOR’S PARTICIPATION IN ANY ACTIVITY OR EVENT INVOLVING DREAM CITY CHURCH IN ANY MANNER. IT IS THE EXPRESSED INTENT OF THE PARTIES TO THIS AGREEMENT THAT THIS INDEMNITY IS EXTENDED TO THOSE ACTS RESULTING FROM THE SOLE, JOINT OR CONTRIBUTORY NEGLIGENCE OF DREAM CITY CHURCH AND ITS AGENTS, VOLUNTEERS, EMPLOYEES, ATTORNEYS, ASSIGNS, AND ALL OF ITS RESPECTIVE SUCCESSORS IN INTEREST.
I (we) acknowledges and represent the following: that I (we) are in fact the parent or legal guardian of the minor and otherwise has the authority to enter into this agreement; that this agreement is supported by valuable consideration, including the ability of the minor being able to participate in activities at DCC; and that this agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns and personal representatives.
Signature of one parent or guardian: