Christ Centered F

Hsnafieiary fiel*ess erld Walver af $*iebility

Project Name: Genlsr.forlhe Shildrqn ot the futurg Project Number: PH oB40
Beneficiary Name: Kg\hrya_ Gat.on 28D
Beneficiary Number: .
OI

fhis form explains the risks of participating in a child development program rurt by christ
centered
Fellowship and require$ qr! you,lhe legal guardian/primary caregiver,lgree
to bear sueh risks. This
lorm must be reviewed.and signed ny you,.t}re boneficiary'u ligalglaroianflrimaiy
caregiver, untes the
beneliciary is legally old enough to give their own conseni in wiictr case heishe can provtde
hisrher own
consent- ln such case the term "my child' shall be taken to refer to the beneficiary il,em
sett.
It is important that you carefully read and unaerstand this release
belore agreeing to it. 6 you do not
understand any section of this form please ask for it to be explained to you.

By signing this form, I confirm: (please lick to confirm you have read and
understood)

={f I have the authority to sign this form wilhout requiring lhe consent of another lagal guardian/
caregiver.

' -&'l allow my child to participate in the Holistic Child and Youth Development program
and other
related programs and services (the 'Programs') funded by Compassion
lnternational, tnc.
{"Compassion").

-fi-l understand that the Programs are lun by Christ Centered Fellowship a local
Christian church
and may include acfivltes such as educatign; medical treatmenl and prevenilve health
care; lield
trips and service acfvities outside the.proiect tocation; correspondenae with
spon$ors through
letters, updates, and photos; visits by sponsors; and any other activity that
may be considered
bene{icial to my child's developnrent.

'4- | understand that participating in any activity, including my child's participation in

this program,
has risks. Pafiicipating in this program has rlsks lncludlng injury, illness,
or death; provlding my
personal data also carrles risk including unautlrorized use
of my name or llkeness; flnancial
lossss, data losses, disclosure of confidential medical lnformation, damage to
honor and
reputation, privacy breaches and identity thefi.

{}- | understand that while Christ Centered Fellowship and Compassion

will have various poii"i*u
and procedures in place to protect rnyself/rny child lrom these risks, they
can never be totally
avoidsd.

-ff- f understand that whfle Compassion wlll provide varlous trafning and
devetopment opportunities
for Christ Centerad Fellowship, Compassion is not responsibla for Christ Centered
Fellowship's actions' Compassion is only responsible for its actions and the
actisns of its staff as
they pertorm their duties.
t-S-t allow lhe Programs'staff and volunteers to make decisions concerning emerg€ncy
medical care
for my child in the course of my child's participation in the Progrr*s. i understand
that program
statf utlll act in good faith on behafi of rny ehlld.
*+-l know of and accept these rlsks to myself and my child and agree to not
make any claims against
Christ Centered Fellowship to the extent that is permissibte under law.

Pagel of2
 ft I relsase, waiVe and farever drSehalge, indemnity and hold hanr{eSs.from tr}y and all
ciairflsj
lialililie€ *nd sauses of astion, whether foresaen *r unicresse*, n:ay arise *ut al, ar rdate
lvhkh
ryf *frFrilaffrsriu, nrrornrysft*lfb par$clpatran rn Gompasslo*-lr:n&.o.prograr*s.

-tr I also exts*d the two csmmitmerrtsai:ove in'rela{on to Caxpresi**

a*d Compassion,s affi}iat*s
(sueh a* its sffice $r reprffientative organization in n:y caunty,
a*d i*i int*mationat partfisrs} a}ld
ils personnal.{such *s emp}oye&s; volunteers and a*y others whc a*1.*n it* b*ha$,

"#- Despits the aftavs three c*rnrnttment$, I rsserve-the right to make'a ulalm.
where ths *r I&
datr4|e sufiered by mpelf o, *y- drild was as a re$trlt ol d;,ihu; **.",
*"o. ir.r bad f.ai*r by
"
.the p+r*o* rausing &e loss cr damage. ln this clrcurr*stance,
I will cnty daim agai:rst src.persrn
or erflty re*p+nsible al.ld nct.any oter"

t under'stand that if I arn not willing to sign Sli$ f6nfi,'Compassion,s pali*ies

-E from."Tpllg may lreyefiI lhem
my'child's applicaticn fcr sp*nsorship supporl $imitarly. if I withdrsw my eansent
al a Jder deie C*mpassbnb prtiaies may $rsvsrli lhenr kcm m*rtnr;r:gl i* oflgl fi'le fu*ding to
. support my child,s place in tre programs.

-*- ln addition, I give Christ Cerrtereci Fel{cw:*hip and Compassion 6e rlglrr to use, and p*rmit
oth+ts t* txive nry citfrd,* orls*at artv*crk {fine nrlurl- in sredia ar nrark*ting {ot any p*rrcss
related io Gornpassion's.mlnistry. Ihis indudes where tTe Work.will be msditicd
or rea*onably
*hanged tor &st pilrpose and wlipther *ra'W.ark ls cradited to rny.ehild ar urcredited
* '
-X.- t sndetBkfld tiat wfuite flTe generel-practiue af Christ Csntrrsd Fellcumhip.and Con:pas*ii:n
k
to a*k for permision or obiections prior to publicatiano they will. B$t be r+quired to do.sa
cnd in
sril?e isrc*rnsfaflces rnay ncf" ti?fiere I expr.ess. an aiil'ei*irbn fo ffre pu$ficafar.: or *>.1t!nued
pu$ication tf a Wbrk I underctemd &at Christ Centered Fellowship
and Connpassian will
, consider thass cbj*ctions in good fafsr-but.may not be abh trr prevenl or re,rrcve t:* wgrft fr*m
publicaiion. I cosrmit srgt neither rny child nsr I will make anylegal
claims regarding&iir

-g- I sigrr this larn:. ireely *nd fully'understand *sch of .th*se p*i*ts arrd Frave had any that I didnt
understand explainsd t0 me.
._|

ay ttry sig*3tine below, I repre*xt ffiet l.*nr #l* lryel guardi*r$rtxary *arrytv* af #3e ffitgr
rnea#lrne* theJosr Ei.d orr be*att sf tt?er,rJosr cS"ild, gra* &nsenf fs #3€ f€rrlrs aiff;s f.e*asE,

Leg*l GuxrdiitnrPrimsry Gxregfuer Carrse$t Benefci*ry Consefit {ff l*Ecal Lqel Haionry
A$e)
Printed Name; Uid\e[{ Galon

SiEn atu rerTh u,mb P; ;it:

[*>':' $ignaiure;

L./ e LC. f de - lJ d. itl

!1*'itryess
Prinled FJame: { te " O r-o.n-
Signature:

Ilria' ,\.

Fago 2 ai2

\
*N *,*, CENTERE* FELLOWTIiIF
Collection Statement
Pers;onal infqrmation
Agreement *11 the Organlzations
consent for the abov*-narnec organizat,u.n bolow) of
your Dara (as explarned
1. This document se* o,,;t .ransrer the'p;;;;r
uuu, or responsible
risteci in creuse 6 to corecr,
you ur"
"ilru'unJ
,"**i"nJon (otther Jil;;:r*gtigt"o'n
. yourserf and the chlld 'o'
' relaflve) acc0rdlng tc'the
tenns below'

Personal Data
addrese'
chiro: ;;;:il".u nr*u",i*mall addiess'.rsstrdentlal
Z,Tttuporsonaldataweintendto-ocllactancJuseforthepurposeslno,uu::-:inolude(ln
ethnic
reration ro you anci/or-rhe
birth' ag;' ;;;il lnfofl'nston' racial or
passporr autriil' aett or
iden{.ty card andlor vldoos fihe DataJ'
cdgln, ;*il"ru' pt'oto r**ilu' '"d
'-rrg*u;
Pr.r rP ose of 'Collection
nd Yo uth
3,'n " n H o rr sti c c hi id a

:.? ffj'Sl-if: iffi :ij}i-T:,'fi,i]HJ?':'$tr'",:

*Programs)'
(the
Developmant
program uno relat*d or*'uni"'uto
oin", "t'i*"
b'Manasement'operetion-';;;i;;nanc€qrtneProgranBsndthechlid'e and
gl:ffi{[i[i.[,T*H :mn H:":'tX Tif 3l,ff ii; n a o rshlp P a oket
c prrbilcsllyncc.ieelbleonllneo,"ii'-i",'*3,.111i'.r"u"nt,,*rspo.dsorsgndother
sinrrar'sponu?, "n.su.yT::I#ililiir"J*ffi:f,i,'ifi;, and anaryzins statl$ucs,
d. Research lor Pt ogram lm.Pr'
or
and rraud incrudrns rnvo*ngaton
; lXffi;T:ffiil.1:TinH:"';::l:"-
comPlelnts and audile' rogulaflo.ns,,o'des
or guidellnos.
by any annr|ca!re|1. rules, wg
f, Dlgclosuros as requlred
p:ron,l'11T *
,* *r,r*n t= m*,.x,oJ us oeing
obllgatorylmandatory,
4. lf you do not provlde
to provlde a plagCI 'J'nu, ti-l- orograrn
for your ohlld.
may be unabie

*"t;"T-:ffi provlded to suoh

orsanrsarlon's pe::":nu,and,lrthe data ls
piovided ro rhe forfne
bs
pu,ty u"[iue proviciers
*no't"t-unably requiro accsss
otherthird pariles, its ilrird
the Jurlsdlcffon
(who mav be outsldo of
re the following affilietes
s. uslt l-;-;;?:;,-rrrred
coiieoted)-l
in which ynuiOut" was in olause 3'
rqulrod forthe purpos's
':ffiiill;; *' rpo":: in craus e 3
- -; [: :ffi
fc, ::[H;;1* i;iil,*Compa#; ;i;atlonal,
o'
tnc' tor tlro ldontlflcation
end
Other affiliares of
ras I ns tir eI r
Til=,
d r;;*_m,tj;xg un",x,'fiJll iHJ: r:*,,,lno,*,ou
ongagelnentinthep'og';;;ndcornmunlcaflonwtththeChild' of lha lnformsttan
,r" [Ou'*O to compiy *,itf" "O'lgatlons
rtho parfies triciause 0 a)-c)
T ,
; ;ffi g#,'*,ffi
os'
{x;;ru;::[ : l?Tffffi lil ii'i; raw en io rcemo nt a ge n cr

I ls requlred for lesal

or stmllar
rosulatory
"i'""
oomPllance PurPosee'
'' 'r.,-"J-'";;',.,-tlofl;;;";t
tq
Accesaq tn trer"sianal ilaJ=

conection of eny
0 You may request acms5 lr: the Data we hold aboui you ol" your Child 1nd
lnaccuracies.
.$0. "i-o ColleciJcn
i*quest s c0py 0f oi rr).aF.e srr enqulry relaTed to this Personellnformedon
Gll Gulllermo at
*lararnent cr'any orher appiicaoie dara pclicy, pleaeo contacl: Ryen
. fig$illerulq@c*.mp*-$si*.n,!Ph
.

'$iFnea:

t\41il(],
[^i Galon

F *renVte gal Gu ardian/F.*sponslh{e pa rfy for

I ef ChtldJ

7 4

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