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Parent / Guardian Information

Child 1

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Child 2

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Child 3

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Child 4

Waiver & Release of Liability

Functions & Activities

Prior to my child’s/children’s participation in the programs and events/activities of Theophilus OPC Church ("the Church"), I acknowledge that certain risks are associated with these activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. By initialing below, I hereby give my consent to and authorize the child(ren) named above to participate in all events conducted by the Church. I further authorize my child to travel with representatives of the Church in private or other vehicles to any such events so conducted. Note: If you desire to limit your child’s participation in any event, please inform the Church in writing in advance of that event.

Medical Treatment Authorization

By initialing below, I hereby consent to and authorize the following: I recognize that there may be occasions where the child/children named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of the Church to seek and secure any needed medical attention or treatment for the child/children named including hospitalization, if in the opinion of the agent such a need arises. Further, I authorize the agent of the Church to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of, any physician, surgeon, or dentist licensed under the laws of the State or County in which the medical care is being sought and on medical staff of any hospital. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment including any treatment a physician, surgeon, or dentist may deem necessary. It is understood that this authorization is given in advance of any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care being required but is given to provide authority and power on the part of the agent to give specific consent to any and all such examination, anesthetic, diagnosis, treatment, or hospital care which the aforementioned physician, surgeon and/or dentist, in the exercise of his/her best judgment, may deem advisable. I hereby authorize any hospital, which has provided treatment to my child to surrender physical custody of the child to the agent upon the completion of treatment.

Release of Liability

By initialing below, this form constitutes agreement by the parent/guardian to assume and accept all risks and hazards inherent in Church related programs, outings, and social activities and to release the Church, it’s employees, board, agents, volunteer assistants, and other persons or entities, including other participants, from any and all liability for damages, losses or injuries to the person or property of the undersigned.


On occasion, the Church takes photographs or makes an audio or videotape recording of children and/or adults involved in church activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in Theophilus OPC publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our Church may allow them to photograph or record our events for news reporting on special interest features. By initialing below, I consent to the use of any such audio or visual record of the child named above to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape, audio recordings, and the Church’s web page.

Parent or Guardian Signature

I give permission for the child(ren) named above to participate in the activities of Theophilus OPC Youth Camping Trip including any special events/activities. In consideration for allowing the participation of the child in the activities of the Church, I hereby consent to the above terms on behalf of the child and agree that this form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

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