Each participant in the off site “Youth Service” at 2005 Annual Meeting of Maine Conference United Church of Christ must complete all spaces on this Consent and Liability Release Form,(CLRF) and the Health and Permission Form for Youth Delegates and Youth Visitors, (HPF) the Authorization for Medical and Dental Care Form, and the Emergency Medical Information Form. A PARENT OR GUARDIAN OF EACH PARTICIPANT UNDER 21 YEARS OLD MUST SIGN BOTH OF THE CLRA FORMS AND THE HPF FORMS.

In order for the participant to attend this event, these forms must be returned to: Annual Meeting, Maine Conference United Church of Christ, P.O. Box 966, Yarmouth, Maine 04096-1966

Please provided the following information: type or print in ink.

PARTICIPANT NAME: ___________________________________________________

BIRTHDATE: ___________MALE: __________FEMALE: ________SS#___________

HOME ADDRESS: _______________________________________________________

CITY/STATE/ZIP: _______________________________________________________

HOME PHONE: ( ) _______________ DAY PHONE: ( ) _______________

I understand that the off site “Youth Service Project” Liability Release given is described as follows:
Youth Service Project – September 25, 2004, 1:00-4:00 p.m. – Bethel Church Calling All Youth – To An Annual Meeting Service Project! Join your friends from throughout the Maine Conference for a Service Project Saturday Afternoon, 1:00 – 4:30 p.m., arranged by the Bethel UCC Church. Transportation will be provided, leaving from the front of the hotel. Make a difference in the Bethel Community! Watch for notices and handouts that describe the service projects. Get your friends together, and make some new ones. It should be a good afternoon! P.S.: You MUST have the Service Project Release signed in order to participate!

I hereby consent to participation of me or of my child in the above-described Event. I have read the informational materials regarding the planned activities. I am aware that in activities, such as Bible study, worship, sight-seeing, using public transportation, and meal functions, the participant may also be asked to participate in various other activities that may involve risk such as service projects, in addition to recreational activities.

I understand that I have a duty to provide primary accident and medical insurance for myself (or for my child) and I declare that I am (or my child is) covered by primary accident and medical insurance.

I RELEASE AND FOREVER DISCHARGE, THE MAINE CONFERENCE OF UNITED CHURCH OF CHRISTTHEIR AGENTS AND SERVANTS, SUCCESSORS AND ASSIGNS, DIRECTORS, TRUSTEES, OFFICERS, EMPLOYEES, AND OTHER REPRESENTATIVES FROM ANY AND ALL DAMAGES AND CAUSES OF ACTION EITHER AT LAW OR IN EQUITY THAT I MANY HAVE AS A RESULT OF MY [OR MY CHILD’S] PARTICIPATION IN, ATTENDENCE AT, AND RAVEL TO AND FROM ANY EVENT. FURTHERMORE, I DO HEREBY EXPRESSLY STIPULATE, AND AGREE TO INDEMNIFY AND HOLD FOREVER HARMLESS THE MAINE CONFERENCE UNITED CHURCH OF CHRIST IT’S AGENTS AND SERVANTS, SUCCESORS AND ASSIGNS, DIRECTORS, TRUSTEES, OFFICERS, EMPLOYEES, AND OTHER REPRESENTATIVES AGAINST LOSS FROM ANY AND ALL PRESENT OF FUTURE CLAIMS, DEMANDS OR ACTIONS IN LAW OR IN EQUITY THAT MAY HEREAFTER BE MADE OR BROUGHT MY ME OR MY CHILD, BY ANYONE ON BEHALF OF ME OR MY CHILD, OR BY ANYONE ELSE ON THEIR OWN BEHALF FOR DAMAGES OR ANY OTHER LEGAL OR EQUITABLE REMEDY ON ACOUNT OF DEATH OF ME OF MY CHILD OR ANY INJURY, ILLNESS, PHYSICAL CONDITION, INCONVIENCE OR LOSS SUSTAINED BY ME OR MY CHILD DURING THE EVENT OR TRAVEL TO AND FROM THE SAME.

I, the undersigned, hereby acknowledge that I have read the foregoing, understand its contents, and have signed the same as my own free act and deed.

FOR PARTICIPANTS AGE 21 AND OVER:

_____________________________
Participant Signature

_________________
Date

__________________________
Witness

FOR PARTICIPANTS UNDER AGE 21: