Christmas Kid’s Night Out

Please Fill Out The Below Form For Every Child That You Would Like To Sign-up

CALVARY CHAPEL SOUTH BAY

PERMISSION SLIP

I/We hereby give my/our permission for my/our child to attend the Calvary Chapel South Bay, Inc. sponsored children's Christmas kid's night out event titled which will occur on December 10th. (the “Event”).

I/We understand that there will be adult supervision at the Event. I/We also understand that if there are any disciplinary problems with the above named minor, it will be our responsibility to pick up our child at the site of the Event and that minor will not be eligible for future events without the specific approval of Calvary Chapel South Bay leadership. I/We give Calvary Chapel South Bay, a nonprofit, religious organization permission to use photography of this minor publically. I/We understand that the images may be used occasionally in print publications, online publications, presentations, websites, and social media. I/We also understand that no monitary compensation shall become payable by reason of such use.

AUTHORIZATION TO CONSENT TO TREATMENT

I/We the parent(s)/ guardian(s) of the minor named below on this authorization and consent form, do hereby authorize Calvary Chapel South Bay, Inc. as agents for the undersigned to consent to any emergency x-ray, examinations, anesthetic, medical, or surgical diagnosis, or the Medical Practice Act on the medical staff or licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this consent and authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given in advance to provide authority and power in the part of aforesaid agents/guardians/parents. This authorization and consent is given pursuant to the provisions of Section 25.8 of the Civil Code of California. The expense of any such treatments and delivery of medical services is agreed to be the sole obligation of the undersigned and not that of Calvary Chapel South Bay, Inc.. Calvary Chapel South Bay, Inc. is hereby released from responsibility to pay for such services and treatments rendered.

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