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412 Summer Retreat on Tuesday, July 16, 2019 @ 6:00 AM

*Parent/Guardian First and Last Name:
*Parent/Guardian Phone Number:
*Parent/Guardian Email Address:
*Student's Grade:
*Student's Gender:
*Student's Age:
I hereby take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns: a) I WAIVE, RELEASE AND DISCHARGE from any and all claims or liabilities for death or personal injury or damages of any kind, EXCEPT THAT WHICH IS THE RESULT OF GROSS NEGLIGENCE AND/OR WANTON MISCONDUCT OR PERSONS OR ENTITIES LISTED BELOW, which arise out of or relate to my participation in 412 Summer Retreat with Calvary Chapel Melbourne, THE FOLLOWING PERSONS OR ENTITIES: Calvary Chapel Melbourne, 412 Viera Youth ministry, event directors, sponsors, and the officers, directors, employees, representatives and agents of any of the above; b) I AGREE NOT TO SUE any of the persons or entities listed above for any of the claims or liabilities that I have waived, released or discharged herein; and c) I INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions. I hereby assign and grant to Calvary Chapel Melbourne the exclusive and irrevocable right to use, copy, sale, distribute, reproduce, publish, broadcast, stream, alter, copyright, exhibit and store my portrait, photograph, image, voice, works of authorship, writings and statements in human perceivable or electronic form, including but not limited to written material, still images, photographs, continuous film, videotape, magnetic tape, audio recordings and sound recordings, without limitation and solely in connection with activities of Calvary Chapel Melbourne. I hereby release and hold harmless Calvary Chapel Melbourne, its agents, licensees and employees, from any and all claims and demands associated with this release, including all claims for libel. I also waive any claim for damages from Calvary Chapel Melbourne for the unauthorized use, copying, sale, distribution, reproduction, publication, broadcast, streaming, alteration, copyright, exhibition or storage of my portrait, image, voice, works of authorship, writings or statements, by any third party gaining access thereto via the Internet or the World Wide Web. I also waive any right to compensation that I may have for the forgoing. I have fully read, understood and executed this release freely and voluntarily. I understand my right to select an independent counsel to explain the significance of this release or understanding that right, have waived it. By signing this document I accept all terms and conditions of this release. :
*By initialing you have read and agree to the terms of the Waiver of Release and Liability:
*Today's Date: