Youth's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Primary Phone Number *

(###)

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Secondary Phone Number *

(###)

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Additional Parent/Guardian *

First Name

Last Name

Primary Phone Number *

(###)

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Secondary Phone Number

(###)

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Full Name of Insured

First Name

Last Name

I agree to this media release *

I, Parent/Legal Guardian of (child’s name listed above), hereby grants permission to St. John UMC, its agents and assigns, to use above named child’s photo or video, and likeness for the purpose of promotion by St. John UMC for all forms, media and manners, for the following, but not limited to, news releases, photographs, video, audio, website/social media, marketing, advertising, trade, promotion, exhibition for an indefinite period of time. I give unrestricted permission for images, videos, and recordings of the child to be used in print, video, digital and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and that these images may be used without further notifying me. I further acknowledge that I will not be compensated for these uses and that St. John UMC owns all rights to the images, videos, and recordings, and to any derivative works created from them. I waive any right to inspect the uses of any printed or electronic copy. I hereby release St. John UMC and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright. This Release expresses the complete understanding of the parties.

Yes

No

I agree to the Code of Conduct *

Code of Conduct As the parent/legal guardian of this registered youth, I agree on our behalf: To abide by the Covenant of Conduct In all meetings, retreats, or other events under the sponsorship and/or guidance of my church, I am a representative of that Christian community and I am responsible for my actions. St. John Leadership/Robbie Brawner has my/our permission to participate in the Youth Mission Immersion, January 17-18, 2020 Please seek any medical assistance while this youth is with St. John United Methodist Church youth group. We hereby grant permission to St. John UMC, its agents and assigns, to use above named youth’s photo or video, and likeness for the purpose of promotion by St. John UMC for all forms, media and manners, for the following, but not limited to, news releases, photographs, video, audio, website/social media, marketing, advertising, trade, promotion, exhibition for an indefinite period of time. I give unrestricted permission for images, videos, and recordings of the child to be used in print, video, digital and internet media. I further acknowledge that I will not be compensated for these uses and that St. John UMC owns all rights to the images, videos, and recordings, and to any derivative works created from them. I waive any right to inspect the uses of any printed or electronic copy. I hereby release St. John UMC and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright. This Release expresses the complete understanding of the parties. I/We have read and understand the above document. By signing this document I/We hereby release St. John United Methodist Church, from any and all liability for personal injury or damage to property.

Yes

No

I agree to the Participation & Liability Release *

St. John United Methodist Church Children and Youth Participation Permission and Liability Release Form.1 I hereby grant my child (listed above) permission to attend and participate in all activities, field trips, and ventures offered by and/or through St. John United Methodist Church, (hereinafter referred to as “SJUMC”) beginning on January 17, 2020, and continuing in full force and effect until January 18, 2020 or this Release is revoked by me in writing and said writing is delivered to SJUMC. I agree that the attendance of my child at any SJUMC activity constitutes my agreement with and acceptance to the terms of this Release. I agree that my child’s picture or likeness may be included in any photographs or videos taken at any such event and used by St. John for any purpose in any medium. I agree that my child may ride in vehicles driven by staff or volunteers approved by St. John to offsite church related events within the municipality of Anchorage, including but not limited to, volunteer/service activities, youth group activities, overnight retreats, sporting events, etc. I accept full responsibility for my child’s actions, and I hereby indemnify and hold harmless SJUMC, its approved ministries, agents, employees and assigns, against any and all loss or damage arising from any and all accidents or injuries caused by my child, whether accidentally or willfully, to: (i) property owned by SJUMC; (ii) property of those acting as employees, agents or assigns (including, without limitation, volunteers and event staff), of SJUMC; and (iii) personal injuries or death suffered by any employee, agent, volunteer or staff member of SJUMC. I further accept full responsibility for my child’s safety and I hereby release, hold harmless, and agree to indemnify and defend SJUMC, its agents employees and assigns, including, without limitation, volunteers and event staff, from and against any and all injuries, damages, claims, and liabilities arising out of, relating to or resulting from my child’s participation in any SJUMC-approved or sponsored activity, except to the extent wholly caused by the gross negligence or intentional misconduct of any such volunteer(s) or staff. In the event of injury to or illness of my child while engaged in a SJUMC-approved or sponsored event, I hereby expressly grant to SJUMC, its agents, employees and assigns, permission to seek such medical care (including emergency treatment) as any of such persons in good faith believe is needed, and I hereby agree to indemnify and hold harmless SJUMC, from all expenses incurred in obtaining medical treatment for my child. Without limiting the foregoing release, under no circumstances shall St. John be liable for any injuries, damages, claims, and liabilities beyond the extent to which the same are covered by insurance.

Yes

No