Chapel Hill Youth & Kids Waiver 2026-2027
Form is for any minor participating in Chapel Hill Youth & Ministry Activities from September 2026 - September 2027
Name of Child/Children
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Name of Parent/Guardian & Primary Emergency Contact
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Phone of Emergency Contact
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Liability Waiver: I hereby give permission to the Safe Place Certified and designated leaders of Portage Chapel Hill Church for the ABOVE NAMED child/children to take part in youth ministry and children’s ministry activities. Should the participant require immediate or emergency medical care while engaged in an activity while in the care of PCH leaders, in my absence, I hereby grant the church authority to release the participant for medical treatment to such medical personnel as the leaders determine appropriate under the circumstances. I agree to release and hold harmless the Church, its officers and agents, from any liability to or responsibility for bodily injury, damage or illness to the above-identified participant while participating in ministry activities. Further, I agree to indemnify and hold harmless Portage Chapel Hill Church, and their officers and agents with respect to any claim asserted by or on behalf of the participant as a result of bodily injury, illness, or damage. This waiver will last until September 1, 2027.
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Please select one option.
Yes
No
Photo Release: Ministry Leaders, at times, will take photographs and/or make an audio or video recording of participants during ministry activities. I consent to the use of any such photos, audio, or video record of the ABOVE NAMED to be used, distributed or displayed as agents of the church see fit.
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Please select one option.
Yes
No
Yes with exceptions I'll explain below
If applicable, from the above question, list any exceptions to the photo release
Any allergies or health concerns of which PCH leaders should be aware?
List the name and phone of any additional emergency contact you'd like on file
Submit
Description
Form is for any minor participating in Chapel Hill Youth & Ministry Activities from September 2026 - September 2027
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