Permission to be involved in Scotia-Glenville Campus Life programs 2015-2016 school year

Functions and Activities

It is my understanding that my child’s participation in programs and activities is a privilege. Prior to my child’s participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.   

Release of Liability

By signing this Permission/Waiver Form, I assume all risks of my child participating in Campus Life activities, whether such risks are known or unknown to me at this time. I further release Campus Life and its leaders, board members, employees, volunteers and agents from any claim that I may have against them as a result of injury or illness incurred during the course of participation in Campus Life activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty.  This release of liability is also intended to cover all losses, liabilities, suits, claims and expenses that members of my family or estate, heirs, representatives or assigns may have against Campus Life or its leaders, board members, employees, volunteers or agents, including fines, penalties and attorneys’ fees. I also assume full responsibility for any and all damages to the site caused by my child.

First Aid Emergency Medical Treatment

I recognize there may be occasion my child may need first aid or emergency medical treatment as a result of an accident, illness or other health condition or injury. I understand that every effort will be made to contact me in that event. If I cannot be reached, I hereby give permission for agents of Campus Life to seek and secure needed medical attention or treatment for my child, including hospitalization, if in the agent’s opinion such need arises. I give permission for attending physician(s) and other medical personnel to administer any and all needed medical treatment required, including injection and/or surgery. In addition, I consent for staff/volunteers to administer over-the-counter medications as Tylenol, ibuprofen, Pepto Bismol, Benadryl, lozenges, cough syrup, ointments, epi pen, if needed (cross out those not consented to), as well as that prescribed by my child’s physician (given to staff prior to participation).


Occasionally, photographs or audio/videotape recordings of youth and/or adults involved in Campus Life activities are taken. Such records may be used by staff or participants to remember the activity. In addition, such photographs and audio/visual recordings may be used in publications or advertising materials to publicize Campus Life activities. In addition, local news organizations may hear of our activities and Campus Life may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of my child to be used, distributed or displayed as agents of Campus Life see fit. This consent includes but is not limited to photographs, videotape, audio recordings and written testimonies.

Name of Child *
Name of Child
Birth date *
Birth date
Parent/Guardian Home Phone *
Parent/Guardian Home Phone
Parent/Guardian Cell Phone *
Parent/Guardian Cell Phone
Allergies to medication, environmental factors, food, etc
Advance notice of this is required. If there are no special dietary needs please write 'none'
Parent/Guardian Signature *
Parent/Guardian Signature
I have read this form and by typing my full name into these fields I am giving permission for the child named above to participate in Scotia-Glenville Campus Life programs for the 2015-2016 school year

Youth for Christ, PO Box 443, 1544 Rt 9, Halfmoon NY 12065; (518) 533-3617 / fax (518) 982-5544;