Carmichael Children and Youth Release and Waiver of Liability (2025)

Please fill out this form and click submit. If you have any questions or concerns, please contact our Director of Children and Youth Ministry, Michael Lombrano (michael@carmichaelpres.org). Thank you!
I hereby authorize and consent to the participation of said minor(s) in the events or activities organized or sponsored by, and attended by, adult staff and authorized volunteers of the Carmichael Presbyterian Church (the "Church") Children and Youth Ministries Programs (the "Programs"). It is specifically understood that this consent and authorization relates and extends to activities held between December 2024 through December 2025 both on the church campus and outside of and beyond the church campus, including beyond the greater Sacramento area. This Release and Waiver of Liability is an important document related to the participation by said minor(s) in the Programs. Therefore, please read it carefully before signing.
 
 
 
 
 
Student Info
 
 
 
 
 
 
 
 
Emergency Contact Info
 
 
Risk Factors and Compliance:
I acknowledge that by participating in the Program my child/ren may be exposed to risks, including but not limited to being exposed to or infected by the novel corona virus COVID-19, and such exposure or infection may result in BODILY INJURY, ILLNESS OR DEATH. I agree that my child/ren will comply with CPC and CDC guidelines to prevent the spread of COVID-19, including but not limited to Social Distancing, wearing a cloth face covering over nose and mouth, maintaining clean hands, and refraining from participation if experiencing any of the symptoms of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

I further acknowledge that: (a) there is some concern and risk relating to travel in general, and (b) the Programs' activities may include but not be limited to sightseeing, bus, automobile, and other means of travel, which may be subject to certain hazards, both natural and man-made. I am voluntarily consenting to the participation by my child/ren in the Programs with full knowledge, appreciation and understanding of the risks involved and hereby agrees on behalf of my child/ren to accept any and all such risks of my child's/children's participation in the Programs. 


I understand that the Church cannot bear or accept liability for the potential hazards that could, if such were to occur, subject them to potential claims. 


I also acknowledge that the Program sponsors have been able to obtain insurance insuring such agencies for liability with respect to such risks and acknowledges and agrees that it is my personal responsibility on behalf of my child/ren to investigate and secure any medical, life, liability, disability or other insurance that I determine is appropriate in my sole discretion. 


I hereby expressly waive the provisions of California Civil Code Section 1542, which provides as follows: 


"A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the Release, which if known by him must have materially affected his settlement with the debtor." 


I recognize and understand that Section 1542 applies to and covers all claims released in this Release, known or unknown, suspected or unsuspected, and hereby expressly waive any rights I may have under Section 1542, as well as under any statutes or common law or principle of similar effect.

By checking the box below you understand the risk factors and agree to be compliant. 
Please select all that apply.
Release and Waiver:
I hereby release and waive all claims, actions, and causes of actions which I, as parent or legal guardian of said minor, might otherwise have against the Church, any member of the Church staff, volunteers, advisors or other persons helping or participating that may arise out of or from any loss, physical, emotional, or mental illness, injury, or death while participating, or as a result of participating in a Church event or activity. I agree that neither I, nor any of my heirs, personal or legal representatives, or family members will bring suit or make a claim for illness, injury, or death resulting from negligence, breach of warranty or strict liability of the Church, and that this release is binding upon my heirs, administrators, and personal representatives.
Please select all that apply.
Publicity and Permission:
I understand that television and radio stations, newspapers and other media sources may contact and visit Church Activities. I grant permission for my child(ren) to be photographed and/or interviewed by such media, and I grant permission for such interviews and/or photographs to be distributed or broadcast to the general public. In addition, I grant permission for photographs and/or video recordings of my child(ren) to be used in any brochures and informative publications or church operated websites and social media describing the Church which may be distributed to the public.

We never want you or your student to feel uncomforatble. We will never force anyone to be in any form of media if they do not wish to be.
Please select one option.
Authorization for Emergency Medical/Dental Treatment of Minor
I am the Parent or legal guardian of the children listed above and I hereby authorize as my agent, under the provisions of California Civil Code Section 25.8, or any successor provision, any teacher of Carmichael Presbyterian Church (the "Church"), any adult advisor to the Church Fellowship programs, any member of the Church staff, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act. It is understood that this authorization is given in advance of any specific diagnosis to provide authority on the part of the agents designated above to give specific consent to any and all such diagnosis, treatment or care which the physician or dentist in the exercise of his or her best judgment may deem advisable. Pursuant to California Health & Safety Code Section 1283, I hereby authorize any hospital which has provided treatment to the minor, to surrender physical custody of such minor to the agents designated above upon completion of the treatment. I further agree to pay all charges for any such care or treatment. This authorization is to remain effective until one (1) year from the date of its execution. 
Please select all that apply.
 
 
Student Medical Information
Please share anything the Carmichael Presbyterian Church leaders should know about your child's health. You do not have to share anything; you can leave this blank if you wish.
 
 
 
 
I understand and acknowledge that my failure to disclose relevant information may result in harm to myself/ my child, and others. I agree to indemnify and hold harmless the Church and its affiliates and other agents from any claims I may make for personal injuries or death of such persons due to my/my child's failure to disclose any such information. I represent and warrant that I have provided all material and important information to the Church pertaining to such minor's medical, mental, and physical conditions, in view of such minor's participation. I further represent and warrant that this information is complete and accurate. 


Please type your full name below. By doing so you recognize that you are signing this document electronically and agree that your electronic signature is the legal equivalent of your manual/handwritten signature on this document. By typing your full name using any device, means, or action, you consent to the legally binding terms and conditions of this document. You further agree that you signature on this document is as valid as if you signed the document in writing.

By typing your name below you are also confirming that you are authorized to enter into this Agreement. If you are signing this document on behalf of a minor, you represent and warrant that you are the minor’s parent or legal guardian.
 

Description

Please fill out this form and click submit. If you have any questions or concerns, please contact our Director of Children and Youth Ministry, Michael Lombrano (michael@carmichaelpres.org). Thank you!