Ninja Jailbreak Event - Registration and Consent Form (To be completed for Youth under 19) March 6, 2013

By signing this form I understand that my child, ________________________________, will be participating in the Ninja Jailbreak Event from 6:30pm to 9:30pm. Transportation and supervision will be provided by the staff of Chilliwack Baptist Church.

Consent I consent to my son/daughters attendance and participation in the Ninja Jailbreak Event. In the event of a medical emergency, I understand that an effort will be made to reach me. However, I give the leaders of the church youth ministries the authority to act on my behalf and to authorize treatment for my child if necessary during the event that the parent/guardian is unable to provide such consent. I also understand that I am liable and agree to pay for all costs and expenses incurred.

I release the church (paid and non-paid staff, members, and volunteers) and event-related companies and staff against all losses, claims, suits, and demands, or any liabilities whatsoever arising from injury or death to the child or other persons involved.

I understand that Chilliwack Baptist Church will collect and securely retain the above information for record-keeping purposes. I give permission for my childs picture and/or name to appear, on occasion, on promotional or invitational materials or website affiliated with Chilliwack Baptist Church.

Parent or Guardian: ________________________________________________________ Signature: ________________________________________________________ Date: ______________

46336 First Avenue Chilliwack, B.C. V2P 1W7 Telephone: 604-792-3988 Fax: 604-792-9053 e-mail:theoffice@chilliwackbaptist.com