MENU

YOUTH ATHLETIC PROGRAM WAIVER

  • YOUTH ATHLETIC PROGRAMS AND ACTIVITIES

  • PARENT/GUARDIAN CONSENT, RELEASE AND WAIVER OF LIABILITY ("RELEASE")
    EMERGENCY CONTACT AND MEDICAL AUTHORIZATION

  • PLEASE READ CAREFULLY BEFORE SIGNING

  • I. Participant Information:

  • II. Parent/Guardian Information:

  • III. Consent to Participate

    As parent, legal guardian or custodian of the minor child (“child” or “participant”) named above, and by signing below, I give permission for my child to participate in Kerwin B. Lee Family Life Center Youth Athletic Programs and Activities (hereinafter the “KBLFLC Athletics”)

    YOU MUST INITIAL BELOW ALONGSIDE THE SPORT YOUR CHILD WILL PARTICIPATE:

  • I acknowledge and understand KBLFLC Athletics will be held at Kerwin B. Lee Family Life Center, 2197 Young Road, Stone Mountain, Georgia 30088. I understand and acknowledge that Kerwin B. Lee Family Life Center ("KBLFLC") is a division of Berean Community Development Corporation, Inc. ("BCDC"). I also understand and acknowledge that Berean Christian Church, Inc. ("BCC") is the legal entity which owns KBLFLC’s property, facility, equipment and furnishings. I understand that my child is only permitted to use the premises while participating in the KBLFLC Athletics program and or activity initialed above and only when he/she is being supervised by KBLFLC’s coach, staff, parent volunteer, or adult volunteer.

  • IV. Release and Wavier of Liability:

    In consideration of the mutual promises, covenants, conditions, representations, and warranties contained herein, and for other good and valuable consideration, the receipt and legal sufficiency of which are hereby acknowledged, and for allowing my child to participate in the KBLFLC Athletics program and or activity initialed above, I am signing as parent or guardian on my behalf and my child’s behalf this PARENT/GUARDIAN CONSENT, RELEASE AND WAIVER OF LIABILITY form ("RELEASE") in the space provided below indicating my acknowledgment, understanding, and agreement with the following:

  • A. ASSUMPTION OF RISKS: I acknowledge, understand and agree that playing or participating in sports and or athletics may be potentially dangerous activity involving risk of injury. I understand the sport initialed above presents my child to dangers and risks of harm, both known and unknown, including, but not limited to, falls, contact or collisions with other participants, equipment or facilities, minor or serious injury (bruises, broken/fractured bones, sprains, or concussions), disability, death, and even property damage, and I hereby voluntarily agree to ASSUME ALL RISKS associated with my child’s participation in the KBLFLC Athletics program and or activity initialed above.

  • B. RELEASE, WAIVER, and DISCHARGE: I, for myself, my heirs, personal representatives or assigns, do hereby knowingly, freely and voluntarily, agree to RELEASE, WAIVE, COVENANT NOT TO SUE and DISCHARGE Kerwin B. Lee Family Life Center, Berean Community Development Corporation, Inc., its board of directors, officers, employees, volunteers, agents, and related and/or affiliated entities, as well as Berean Christian Church, Inc., its board of directors, officers, pastors, employees, volunteers, agents, and related and/or affiliated entities from and for any and all liability for injuries, illness (including death), damages, medical expenses, or any other loss, claims, causes of action, including negligence resulting in personal injury to my child, or family or me (including attorney’s fees) which may arise from or related to my child’s participation in KBLFLC Athletics program and or activity.

  • C. NDEMNIFY, DEFEND and HOLD HARMLESS: I agree to INDEMNIFY, DEFEND, and HOLD HARMLESS Kerwin B. Lee Family Life Center, Berean Community Development Corporation, Inc., its board of directors, officers, employees, volunteers, agents, and related and/or affiliated entities as well as Berean Christian Church, Inc., its board of directors, officers, pastors, employees, volunteers, agents, and related and/or affiliated entities from any and all claims, demands, losses, judgements, costs and expenses, including reasonable attorney’s fees, arising out of or related to any INJURY, DISABILITY OR DEATH or loss or damage to person or property AS A RESULT OF THE NEGLIGENCE OF KBLFLC, BCDC, BCC OR OTHERWISE during my child’s participation in the KBLFLC Athletics program and or activity initialed above. This indemnification shall survive the termination of the RELEASE.

  • D. Any questions I have concerning my child’s participation in the KBLFLC Athletics program and or activity initialed above have been answered.

    E. I certify that my child is in good physical and mental health and is able to participate in the KBLFLC Athletics program and or activity initialed above without medical supervision.

  • F. As a parent/guardian, I further acknowledge that I am an influential figure in my child’s life and agree that participation in sports and athletic activities contributes to his/her learning experience. Therefore, I will show respect for all players, coaches, spectators, and officials. I will only participate in cheers that support, encourage and uplift the teams involved. I understand the spirit of fair play and good sportsmanship expected by KBLFLC, BCDC, and BCC and accept the responsibility that comes with being a parent/guardian of a child participant.

    G. Should any portion of this RELEASE be deemed to be unenforceable or contrary to public policy, the remaining portions of this RELEASE shall survive and be enforceable. This RELEASE shall be governed by and subject to the laws of the State of Georgia.

  • I certify that I am at least 18 years of age, competent and am the parent or legal guardian of the minor child named above. I certify to the best of my knowledge, I have provided true, correct and accurate information in this document, and I have read the above PARENT/GUARDIAN CONSENT, RELEASE AND WAIVER OF LIABILITY provisions and fully understand the terms contained in each provision, and understand that I am giving up substantial legal rights, which includes a COVENANT NOT TO SUE. I ACKNOWLEDGE THAT I AM SIGNING THIS DOCUMENT FREELY AND VOLUNTARILY.

  • V. Emergency Contact and Medical Authorization

    A. EMERGENCY CONTACT:

  • B. MEDICAL AUTHORIZATION:I hereby give my permission to the KBLFLC coach, KBLFLC staff, or medical personnel selected by the Director of The Kerwin B. Lee Family Life Center to secure emergency medical treatment including but not limited to, first aid, CPR, authorize emergency transportation, admission to any hospital, tests, surgery or general anesthesia, so long as care is provided by persons or facilities licensed in the State of Georgia. I understand that a conscientious effort will be made to locate me in case of an emergency. However, in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the director to secure and administer treatment, including hospitalization, for the child named above. Additionally, I give permission to DeKalb Medical Center, 2801 DeKalb Medical Parkway, Lithonia, GA 30058 to treat my child. I further acknowledge that any medical treatment ordered is my financial responsibility and not that of the Kerwin B. Lee Family Life Center, Berean Community Development Corporation, Inc., its board of directors, officers, employees, volunteers, agents, and related and/or affiliated entities, as well as Berean Christian Church, Inc., its board of directors, officers, pastors, employees, volunteers, agents and related and/or affiliated entities.

    I CERTIFY THE ABOVE EMERGENCY CONTACT INFORMATION IS TRUE AND CORRECT AND I CONSENT TO THE MEDICAL AUTHORIZATION WRITTEN ABOVE.

WordPress Lightbox Plugin
X