“The Women’s Retreat” Permission Slip

I give permission for my student to attend the “April 26th - 28th, 2024” weekend event *

Yes

No

Student's Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Gender

Female

Male

Parent #1 Name *

First Name

Last Name

Parent #1 Phone Number *

(###)

###

####

Parent #2

First Name

Last Name

Parent #2 Phone

(###)

###

####

Family Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name Of Emergency Contact

First Name

Last Name

General Release - Participation

I, as primary guardian of the aforementioned student give permission for my student to participate in the “April 26th - 28th, 2024” weekend event.

First Name

Last Name

Release *

La Jolla Presbyterian Church (LJPC) from all responsibility related to medical issues, illnesses, or injuries that may occur to my child during any activities at the “April 26th - 28th, 2024” weekend event. The Participant/parents/legal guardian accepts personal financial responsibility for any injury or other loss sustained during the activity or event and releases and promises to indemnify, defend, and hold harmless LJPC, the LJPC staff, volunteers, or other attendees for any illness or injury arising directly or indirectly out of the activities or events. I acknowledge that participation in the activities or events involves risk to the Participant. No matter the injury, I acknowledge and accept the risks of injury associated with participation in the event. I further accept full responsibility for any medical expenses that may be incurred in the event my child needs emergency medical treatment and I promise to indemnify, defend and hold harmless LJPC, LJPC staff and volunteers, or other attendees for any medical expenses incurred by my child.

Yes

Departing from Program/Events *

APPLIED TO ALL STUDENTS AND CHILDREN I agree to pick up or arrange for my student to be picked up from program/event within 10 minutes of stated end time.

Yes

Films

I agree to allow my child to watch any films rated G, PG, or PG-13 which may be shown (at the Youth Director’s discretion) as devotionals, bible study segments, or for entertainment purposes. I understand that whenever possible, film titles will be provided ahead of time. I understand that the youth leaders will never show an R rated movie without my permission and a separate permission slip will be provided if such a case were to occur.

Yes

No

Media Consent *

I hereby give my full consent to La Jolla Presbyterian Church (LJPC) and its ministries to record (video, photograph, audio, recording or other) my and my child's participation in any programs or events associated with LJPC "One Day" Event. Further, I hereby transfer and assign to LJPC the exclusive rights to use and to authorize others to use said images, video, photography, audio recordings or other, for promotional and educational use or resource sale in the future. I understand that my and my child’s image, voice or video recording may be used, but my name or personal information will never be shared publicly without additional, separate consent.

Yes

No