Youth Waiver Form

Youth Name *

First Name

Last Name

Youth Date of Birth *

MM

DD

YYYY

Youth Gender

Male

Female

Youth Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School Year *

Year 5

Year 6

Year 7

Year 8

Year 9

Year 10

Year 11

Year 12

Year 13

Other

Emergency Contact Name *

First Name

Last Name

Swimming Confidence Level *

Beginner / Unconfident

Medium / Moderately Confident

Expert / Very Confident

The Parent or Guardian of the Participant named above, hereby authorises and consents to the Participant’s involvement in the Lifechurch Tauranga youth program, including any use of private or public transportation deemed necessary by the persons in charge of the group for Participant's travel to and from group activities, or to the nearest suitable medical or hospital facility in the event that emergency or other medical treatment is not available at the site of a group activity. I hereby consent to and authorise such emergency or other medical treatment of the Participant as may be deemed advisable in the event of accident, injury, or illness during the activities of the group. I also understand that the Participant may be photographed or videoed and these photos or videos may be used for the purpose of promotion or advertising by the Lifechurch Tauranga Trust. *

I Agree

I Disagree

I understand that Lifechurch Tauranga Trust and its leaders, staff, volunteers, and representatives are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, activities or travel with Lifechurch Tauranga Trust. *

I Agree

I Disagree

I understand that this youth group is about fun and community. I therefore authorize the person incharge to get in touch with the named participant (within reason) outside of the youth group times, directly or through me, to check on them and/or invite them to other such opportunities *

I Agree

I Disagree

I will talk to the named participant about their safety, recognizing and reporting abuse, respect for other participants, being helpful and responsible.

I Agree

I Disagree