2020 Waiver Form

Name _______________________________ Date of Birth _____________

Photo Release
I give Maine Ministry Outreach Center the right to use my child’s (own - if 18 or older) picture taken at
October Chill for advertising purposes.

o I DO GIVE my permission.

o I DO NOT want my child's (own - if 18 or older) photo used

Parent/Guardian Consent and Agreement

In consideration of my child’s (own - if 18yrs or older) (name listed above) opportunity to participate in
Maine Ministry Outreach Center's (MMOC) October Chill, I acknowledge and accept the risks of injury
associated with participation. I accept personal financial responsibility for any injury or other loss
sustained during October Chill, as well as for medical treatment rendered to my child (myself - if over
18yrs old) that is authorized by MMOC and its leaders, employees, volunteers, or agents. I specifically
consent to allowing my child (myself - if over 18yrs old) to be transported to receive emergency care and
to be responsible for all financial charges for such emergency care. I release and promise to indemnify,
defend and hold harmless MMOC, its leaders, employees, volunteers, and agents from any and all injury
or loss resulting directly or indirectly from the activities and programs of MMOC whether such injury
result from the negligence of MMOC, my child (myself - if over 18yrs old), or otherwise.

Printed Name of Parent/Guardian (Self if 18 or older)

__________________________________________________ Date __________________

Signature of Parent/Guardian (Self if 18 or older) ________________________________________