OFFICE OF THE BASE CHAPLAIN

ATTN: Youth Ministry Coordinator

Fairchild Air Force Base, Washington 99011

TRIP NOTIFICATION/AUTHORIZATION

Name(s):______is/are a member of a chapel group (CLUB BEYOND) which has planned anSpring Weekend Camp at Island Lakeand is planned for April 11-13, 2014 .

From - 11:30am April 11to - 6:00 pmApril 13

If you give your permission for your son/daughter to attend this camp, please provide the information requested below and return it to Toby Broemmeling.

Toby Broemmeling (509) 251-5972,

*****************************PLEASE DETATCH & RETURN**********************************

PARENT’S AUTHORIZATION, RELEASE, HOLD HARMLESS AND MEDICAL CONSENT

DATA REQUIRED BY THE PRIVACY ACT OF 1974

TITLE: Parent’s Release, Hold Harmless and Medical Consent

AUTHORITY:Section 10, USC 3547

PRINCIPAL PURPOSE(S):To obtain permission, hold harmless and medical consent for participation in chapel.

ROUTINE USES:For chapel youth to participate in chapel activities to include off FAFB property in POV

DISCLOSURE:Mandatory. If information is not provided, individuals will not be allowed to participate.

In consideration of my child’s opportunity to participate in CLUB BEYOND Spring Weekend Camp at Island Lake (11-13April2014) and related activities, and for other good and valuable consideration, I, on my own behalf of my child and his/her family, heirs, assigns, executors and administrators, make the following representations, covenants, and releases: I do hereby waive, release, and forever discharge any and all rights and claims for damages which I or my child may have or which may hereafter accrue to me or my child against the United States or its offices, agents, employees, or instrumentalities, acting officially, or otherwise, for any and all loss, damage, injury, or death which may be sustained, suffered or caused by my child during his/her participation in, attendance at, or travel in connection with to and from CLUB BEYOND OpX weekend camp at Miracle Ranch on 11-13April 2014 and related activities. I have read the above, understand it, and my signature confirms its full acceptance.

In the event of illness or injury occurring to my child, during his/her participation in the above named event or program, I do hereby consent in advance to whatever x-ray, examination, anesthesia, medical or surgical diagnostic procedures or treatment is considered necessary in the best judgment of the attending physician and performed under the supervision of a member of the medical staff on any hospital furnishing medical services in connection with programs of the chapels. I understand that, in the event of illness or injury, all reasonable efforts will be made to reach me.

I hereby assign to FAFB Religious Support Office AND Club Beyond Ministries (MCYM) all rights to video and audio recordings and all photographs of my child made in connection with FAFB Chapel and Club Beyond activities. I hereby authorize editing, duplication, reproduction, copyright, exhibition, broadcast and/or other use and distribution of such recordings or quotations for purposes deemed suitable by FAFB Religious Support Office AND Club Beyond Ministry. I also waive any right to approve or disapprove the finished products.

I have read the foregoing Parental Permission, Waiver and Release Agreement before affixing my signature below, and warrant that I fully understand the contents thereof.

NAME OF PARTICIPANT(S)
1.
2.
3.
4. / PARENT’S SIGNATURE (OR SIGNATURE OF ADULT PARTICIPANT) / DATE
PRINTED NAME of PARENT (OR PARTICIPANT IF OVER 18): / CELL PHONE
MOM:
DAD: / ADDRESS (STREET, CITY, STATE & ZIP CODE)