PDY

Online Event Release Form

This is the Event Release Form which is needed for EACH event. 

*One form may be filled out for the entire Summer Pond Party Schedule

PDY
Event Release Form

As a parent/legal guardian of

I have reviewed the information about 

I give permission for the subject of this release to be involved in the overall activities.  It is understood that the subject of this release will obey all regulations and follow instructions of the leaders and representatives of the student ministry of Pleasant Dale Church of the Brethren. I agree to pay any expenses incurred as a result of disciplinary issues, including the cost of transporting the student home if deemed necessary.  I understand that all reasonable safety precautions will be taken at all times by Pleasant Dale church of the Brethren and its agents during the events and activities.  I understand that every activity sponsored by this church is carefully planned and supervised by mature adults.  However, even the best of planning and precaution, I know that unforeseen events can occur.  I understand the possibility of unforeseen hazards and know the inherent possibility of risk.  Therefore, I accept full responsibility for this student's participation in Pleasant Dale church of the Brethren activities, including transportation to and from any location in connection with church sponsored activities. I also agree that I will not hold Pleasant Dale Church of the Brethren or its employees or volunteer workers or members liable for damages, losses, illnesses, or injuries incurred by the subject of this form.  I will assume full responsibility for any medical costs incurred in the even of an accident or other incident requiring medical treatment.  I release Pleasant Dale Church of the Brethren from any liability.  In the event of an emergency in which the student is in need of immediate hospitalization, medical attention or surgery, and after reasonable efforts have been made to contact me and the other emergency contacts listed on the Student Medial Form & Release and we cannot be located for the purpose of consenting.

In Case of Emergency Contact

Parent(s) or Legal Guardian(s) Name:

Parent(s) or Legal Guardian(s) Phone Number:

Emergency Contact Name:

Emergency Contact Phone Number:

**Pleasant Dale Church of the Brethren cares for the safety of your student, so help us out by placing a check by the appropriate line below.

My signature is substituted by giving my full name and email below for verification of this Event Release Form.

Thanks for submitting!