Let us know if your child will have special dietary or medical needs.

The undersigned (collectively, “Parent”), being the parent(s) or legal guardian(s) of the above named child (the “Minor”), hereby consent to Minor’s participation in the activity named above (the “Activity”), to be sponsored in whole or in part by Northpark Community Church (“Northpark”).

Parent hereby grants permission to Northpark to record in video, audio, or any other formats Minor’s participation in the Activity, and to the use from time to time of such recording in any form in connection with any Northpark-related events, programs, and promotional activities.

In the event that representatives of Northpark are unable to reach Parent at any of the given telephone numbers, and, in Northpark’s reasonable judgment Minor requires emergency or urgent medical or dental care, Parent hereby consents and authorizes an employee or other adult representative of Northpark to cause such emergency or urgent medical, surgical, or dental examination, diagnosis or treatment, and/or hospital care, to be rendered to Minor under the supervision and on the advice of a physician, physician’s assistant, nurse, or dentist duly licensed under the provisions of California law. Parent agrees that Parent shall be responsible for, and hereby agree(s) to pay, all costs and expenses incurred in connection with such medical and dental services rendered to Minor pursuant to this authorization, including any medical transportation costs.

Parent agrees to indemnify, defend and hold harmless Northpark Community Church, its employees, representatives and staff of the Activity from any liability that may result directly or indirectly from the minor's participation in the Activity. This waiver and release shall include without limitation: (a) any injury, illness, death, property damage or loss to Minor which may be caused by any act or failure to act by the staff or volunteers of Northpark and/or the Activity; (b) loss or damage to, or theft of, Parent's or Minor's personal property; or (c) the interruption or cancellation of the Activity, for whatever reason.