I give permission for my child, as named above, to participate in Sea Road Christian Church’s sponsored event, as named above, on the dates listed above. I hereby release Sea Road Christian Church, its employees, agents and volunteers from responsibility and liability for any illness or injury that the above named child may sustain during any activity.

In the event of an emergency, I hereby authorize an adult leader of the activity, as an agent for me to consent to any x-ray examination; medical, dental, anesthetic, or surgical diagnosis; treatment; and hospital care advised and supervised by a licensed physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are to be rendered, either at the physician’s office or in a hospital. I understand the activity director will endeavor to reach us should the nature of the injury or illness warrant it. However, we will not hold any of the activity personnel responsible if efforts to contact me (us) are unsuccessful. I further promise to hold harmless Sea Road Christian Church and/or its employees, agents and volunteers from any and all expense incurred pursuant to this authorization in obtaining medical treatment and/or transfer, including but not limited to: ambulance expense, cost of paramedics, hospital expense and/or physician charges.

I hereby grant permission for the image of the child(ren) listed on this form to be included in pictures, promotional material, and publications connected with Wyld Wednesday at Sea Road Christian Church. I understand that the child(ren)(s) picture(s) may appear in publications and promotional materials, such as, but not limited to, Church Newsletter, PowerPoint Presentations, Church’s websites www.searoadchurch.org and www.searoadchurch.churchcenter.com; church brochures, postcards, and flyers.