Lighthouse Cafe Parental/Guardian Consent Form

Your name *

Email address *

Phone number

Volunteer's Name *

Birthdate *

Address *

Any allergies? *

Yes

If so, what are they?

Medical note

Emergency Contact *

Phone number *

Secondary Emergency Contact *

Phone number *

Youth Liability & Parent Consent *

This is a legal document. By checking this box you are agreeing to give up certain legal rights including the right to sue. You are also assuming certain obligations.

I understand that my child's participation at the Lighthouse Cafe involves certain risks, including the risk of contracting COVID-19. Notwithstanding this, I hereby release and forever discharge the Lighthouse Cafe and Centennial Road Standard Church (C*Road Church) and all affiliates, members, directors, officers, leaders, agents, volunteers, and employees from any and all actions, causes of action, suits, claims, demands, liabilities, including negligence, and expenses I have now or may have in the future in connection with, arising from or related to my child's involvement with or participation in these activities.

Media Release

By checking this box, I grant Lighthouse Cafe, its representatives, and employees the right to take photographs of my child in connection with the Lighthouse Cafe. I authorize Lighthouse Cafe, its assigns and transferees to copyright, use, and publish the same in print and/or electronically.

By checking this box, I agree that Centennial Road Standard Church may use such photographs of my child for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Internet content.

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