Anchor Youth Waiver
The activities of the Anchor Youth Group at Anchor Church of Virginia Beach involve a variety of events to include group games, trust building exercises, tactile problem solving initiatives, and other physically challenging activities. The level of participation in the activities is at all times completely up the the individual's choice. Yet, there is a risk that must be assumed by each participant, that he/she may suffer an emotional or physical injury or disability. Policy for participation in the Anchor Church Youth activities requests that every participant have healthy/accident insurance coverage. In addition, certain health/medical information must be known to the facilitator/s conducting the program so that they are prepared to respond appropriately if the need arises. This information will be held in confidence. Please complete this form, answering the questions below prior to participating in any activity.
Sign in to Google to save your progress. Learn more
Student's Name *
Parent's Name *
Parent's Email *
Parent's Phone Number *
Medications you take for current medical conditions. (asthma, allergies, etc)
Medications you take occasionally. (headaches, etc)
Do you plan to bring these or any other medications with you? All medications must be brought in the original bottle (prescription or over the counter) properly labeled as prescribed by law.
 *
Required
Do you have, or have you had any recent serious injury?
 *
Required
If you answered yes to the above question, please explain.
Do you have a chronic medical condition?
 *
If you responded yes to the above question, please explain.
Do you have a history of heart attack, by-pass/angioplasty, angina or any other cardiac condition?
 *
Are you diabetic?
 *
Do you have any other medical conditions?
 *
If you responded yes to the above question, please explain.
Do you have any food allergies, medication allergies, or are you allergic to insect bites? *
Required
If you responded yes to the above question, please explain.
Release of Liability: Agreement to Participate: Assumption of Risk and Release
I understand that during the said activities (team building, relaxation, lake fun) that the applicant is requested to participate in, that certain risks and dangers may occur. These include, but are not limited to the hazard of depending on other people and being at various heights (0-40ft), accident or illness in remote places without medical facilities, the forces of nature and travel by air, boat, automobile or other conveyance. The undersigned further recognizes risks may also include loss or damage to personal property, physical or psychological damage and/or injury not excluding fatality due to accidents which may occur, including accidents resulting from course experience or other type of outdoor activities. I further understand that in participating in the activities I am requesting to participate in, I will be exposed to elements of nature including inclement weather. I understand that my participation in the Anchor Church Youth program is entirely VOLUNTARY and that I may excuse myself from participation if I so desire. I hereby give permission for the person named on this form to participate in all activities and I have read the "Agreement to Participate: Assumption of Risk and Release." I hereby release Anchor Church of Virginia Beach from any responsibility other than normal supervision and care. In case of accident, I will not hold Anchor Church or its staff members, management, or volunteers liable.  
I hereby authorize my students picture to be used on social media/website/print for Anchor Church.
 *
Required
Parent/Legal Guardian Signature
 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Anchor Church. Report Abuse
Google Forms