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I, ______________________________________ give permission for ___________________________________to
participate with World Harvest Outreach (in care of Nick and/or Diane Helman, Brian and/or
Audrey Baine, Mark and/or Dawn Durniak or other youth leaders or volunteers) to participate in
youth activities, travel, games and other events. I release World Harvest Outreach (WHO) from all
liabilities, including any injury to my child arising from participation in activities. I agree to
indemnify WHO for any liability due to the child's participation in activities.
I give permission for WHO to seek urgent or emergency medical services for my child. I agree to
incur all financial liabilities required if care becomes necessary. I understand that WHO will
contact me before care is needed, but in the event I am unavailable, care will be sought without my
immediate consent.
I understand this consent is valid beginning today, ______________________(date) through the calendar
year of 2014, ending December 31, 2014.

Parent or Legal Guardian Signature: ____________________________________________________________________
Parent or Legal Guardian Name (printed): ______________________________________________________________
Address: ____________________________________________________________________________________________________
Phone (home): ____________________________________________ (cell): _________________________________________

1090 Wayne Avenue | Chambersburg, Pennsylvania U.S.A | (717) 709-1126 | |