Youth Name:___________________________________________________________

Street:________________________________________________________________

City:________________________________ ST:______________ Zip:____________

Phone:___________________________ Date of Birth:_________________________

Name of Parents (or legal guardian):________________________________________

_____________________________________________________________________

Insurance Company:_____________________________________________________

Policy Number:_________________________________________________________

I hereby give my consent for my daughter/son,

(name)________________________________________________________________

to participate in (event) __________________________________________________

including travel from and to (location) _______________________________________

______________________________________________________________________

(S)he will be traveling by (means of transportation)
______________________________________________________________________

I understand that neither the Maine Conference, United Church of Christ, nor the
staff, is liable in the event of an accident or injury to my child. I also assume full
responsibility for the consequences of my child's actions during these activities.

Waiver of Risk

I understand that, despite careful and proper preparation, there is still a risk of injury when
participating in any activity.

In consideration for the Maine Conference, United Church of Christ, or any other participating
organization, permitting my child to participate in the above activity, I agree to indemnify, defend,
hold harmless and release the United Church of Christ, or any other participating organization,
and their officers, agents, representatives, employees, and volunteers, against and from any and
all claims, suits, losses, costs, damages, expenses, and liability arising out of any act or
omission or other occurrence, whether or not caused by or resulting from this activity, the
United Church of Christ, or any other participating organization, their agents, representatives,
employees, and volunteers during the course of the activity in which he or she is participating.

_____________________________________________________________________________
Signature of Parent or Legal Guardian

Date:_______________________