Discipleship Consent and Release Form

I, the undersigned parent or guardian, hereby consent to my child, participating in Youth Ablaze’s Discipleship Program sponsored by Lighthouse Baptist Church. Every Wednesday after school, my child has my permission to stay in Lighthouse Christian School’s after school care until about 4:00 pm. At that time, my child has my permission to go to Pastor Garritt Jeffers and Mrs. Kaitlyn Jeffers’s home where Pastor Jeffers will teach the teens a lesson. After the lesson, my child will be provided with dinner before returning back to the church for youth group. The entirety of this program is free of cost, including dinner each Wednesday. I certify that my child is able to participate in this program including transportation to and from said program, and I agree to allow them to be accompanied by Pastor Jeffers and Mrs. Kaitlyn Jeffers.

If my child has medical conditions that may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize the school official to make emergency medical decisions for my child. If there are any activities I do not want my child to be involved in, I have listed them below.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED DURING SAID PROGRAM, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do hereby agree to hold Lighthouse Baptist Church and its agents and

employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the program or participation in any other associated activities.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Pennsylvania and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

Child's First Name

Child's Last Name

Child's Date of Birth

Month

Day

Year

Child's Allergies/Medical Conditions

Telephone number where I may be reached in an emergency

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF, AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement that I have read and understand.

Parent or Legal Guardian's Signature

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