Each participant in the off site “Youth Service Project” 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 24, 2005, 11 AM – 2:25 PM. Calling All Youth – To An Annual Meeting Service Project! Join your friends from throughout the Maine Conference for a Service Project on Saturday, 11 AM – 2:25 PM arranged by the UCC Church of Bethel. 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 will be a great opportunity to DO JUSTICE, rather than talking about justice! P.S.: You MUST have the Service Project Release signed in order to participate!

I hereby consent to the participation of my child (my participation) 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 CHRIST THEIR 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, ATTENDANCE 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, SUCCESSORS 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 ACCOUNT OF DEATH OF ME OF MY CHILD OR ANY INJURY, ILLNESS, PHYSICAL CONDITION, INCONTINENCE 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 AGE 21 AND UNDER:
___________________________________________________                 
Parent/Guardian of Youth Participant-If Participant is under 21
Date ___________________________________
Witness ___________________________________

Mail with Annual Meeting Registration Information and Health Permission Form to:
Annual Meeting Youth Service Project
P.O. Box 966
Yarmouth, ME 04096-1966

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