Belay Youth Ministry - Connect Form 2024-2025

First Name

Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Grade

What are you signing up for

Middle School Club (6th-8th Grade)

High School Club (9th-12th Grade)

Are you a part of a local church

Yes

No

If you are a part of a local church, which one?

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone Number

Family Doctor Name

Phone Number

Please list any health concerns or limitations that we need to be aware of.

In consideration for their participation at Belay Youth Ministry facilities and programs onsite as well as offsite, the Adult / Parent and Child agree as follows:

Adult / Parent and Child consent to participation and attendance in programs offered at Belay Youth Ministry which may include participation in off-site events or field trips. Adult / Parent and Child also give staff permission to transport Child to and from the program or activity if needed and to any off-site events. The Adult / Parent and Child represent that they are fully capable of and physically able to participate in the programs as well as any other activities offered by Belay Youth Ministry. The Adult / Parent or Child represent that they will not be under the influence of alcohol or any chemical substance or medication except medication specifically disclosed in writing to the staff at Belay Youth Ministry.

By participating in the programs and activities, the Adult / Parent and Child realizes the risks of participating in such programs and activities. Belay Youth Ministry will take reasonable precautions to ensure that programs and activities at are conducted by qualified personnel in a responsible manner. However, the Adult / Parent and Child further acknowledge and accept that participation in the activities involve inherent risks and dangers. The Adult / Parent and Child understand that risk and injury might result from their own actions, inactions, or negligence; from the action, inaction, and negligence of others, or from the condition of the facility or any equipment used. The Adult / Parent and Child acknowledge that all of the activities are strictly voluntary. It is always the responsibility of the Adult / Parent and/or Child to limit participation in any way he/she deems appropriate.

Adult / Parent and Child give permission to use (including but not limited to taking photographs and making audio recordings or videos), without charge and without reservation, all or a portion my story including my likeness and my voice in promoting Belay Youth Ministry. Further, Adult / Parent and Child grant Belay Youth Ministry permission to use, without compensation, Child’s image, likeness or voice in connection with any promotional materials including, but not limited to, brochures, advertising and broadcasts. Adult / Parent and Child acknowledge that editorial changes may be made as deemed suitable byBelay Youth Ministry. Whether or not changes are made, I waive any rights of action I may have and release Belay Youth Ministry from any and all claims I may have arising from the use, publication, and changes in the content, including any rights to sue for defamation or violation of rights of privacy or rights of publicity.

Consent the use of my child's likeness (ie. photo, video or the like) in any media form. (required)

I do give consent

I do not give consent

By participating in programs and activities offered, the Adult / Parent and Child completely waive and release, on behalf of him or herself, and on behalf of his or her children and wards, Belay Youth Ministry, and persons including but not limited to their board members, officers, staff employees, and volunteers, from any and all claims, actions, suits, demands, liabilities, losses, costs, and expenses (including but not limited to reasonable attorney’s fees), and damages of any nature arising out of or incidental to their use of Belay Youth Ministry's property or participation in Belay Youth Ministry’s programs and activities.

The Adult / Parent and Child shall defend, hold harmless, and indemnify Belay Youth Ministry, its board members, officers, staff employees, and volunteers, from any and all claims, actions, suits, demands, losses, costs, expenses (including but not limited to reasonable attorney’s fees), injury, death, or damages caused by or resulting from their use of Belay Youth Ministry’s property or participation in Belay Youth Ministry's programs and activities.

My electronic signature below certifies that I have read and have understood this agreement and voluntarily agree to all of its terms.

Signature

Date Input

About

Programming