NAME (please print)

_____________________________________________________________

PV: Sr____ Jr____ Soph____ Fresh____ or Jr High 8th____or 7th____

Friday, March 28 9pm-6am

Please fill out all forms: Permission slip and Accident Waiver & Release of Liability

The following rules have been implemented for the safety of all the students/guests attending and must be followed without exception:

1) All students must have a signed liability waiver, signed by their parents/guardians.

NO WAIVER, NO ENTRANCE, NO EXCEPTIONS!

2) No Alcohol, No Drugs, No Smoking, No Weapons.

3) Any bags, backpacks, purses will be checked in.

4) No outside food or drinks allowed, unless for dietary needs.

5) If the student does not show up by 10:00pm, the student will not be let in.

6) All students must exhibit appropriate behavior at all times and follow Victory Center policies.

My child and I understand the above stated rules and agree to follow them.

Student/Guest

signature:___________________________________________________

Parent/Guardian

signature:____________________________________________________

Parent/Guardian Name (please

print)_________________________________________

Home Phone:______________Parent Cell:________________Student

Cell:___________

Victory Center Lock-in ACCIDENT WAIVER AND RELEASE OF LIABLITY

I acknowledge that the Victory Center Lock-in is an event that involves risks. I hereby assume all risks associated with my child’s participation in this event.

I acknowledge that this Accident Waiver and Release of Liability form will be used by the holders, sponsors, vendors and organizers of the event and that it will govern my actions and responsibilities at the event, including travel to and from the event. I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns as follows:

A) waive, release and discharge Community in Action including all units and councils, and all of their officers, directors, members, parents and volunteers; and all their directors, officers, employees, representatives and agents; as well as any vendors, sponsors and organizers of the event, from any and all liability, loss and cost, claim, damage and cause of action of any kind and

B) indemnify and hold harmless the entities or persons mentioned in this paragraph from any and all such liabilities or claims made as a result of participation in this event.

I hereby consent to receive medical treatment, that which may be deemed advisable, in the event of injury, accident or illness during this event.

I understand that I may be photographed at this event. I agree to allow my photo or video to be used for any legitimate purpose by the event holder and assigns.

This Accident and Release of Liability Waiver shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I hereby certify that I have read this document, that I understand its content and consent to its use.

____________________ _____ ___________________________________ Participant’s Name (print) Age Participant’s Signature Date

Parent/Guardian Waiver:

The undersigned parent/guardian does hereby represent that he/she is, in fact, acting in such a capacity and agrees to save and hold harmless and indemnify each and all of the parties on behalf of the minor and parents or legal guardians.

I hereby certify that I have read this document, that I understand its content and consent to its use.  

_____________________________ ________________________________

Parent/Guardian’s Name (print) Parent/Guardian’s Signature Date