Coffee Break Registration Form

Name

First Name

Last Name

Phone

(###)

###

####

Text

Email Address

Study Choice

Child(ren)

Child 1

Child 2

Child 3

Media Consent *

I agree that photographs and/or videos may be taken of me and/or my child at Mountainview Christian Reformed Church programs and events, and may be used in the promotion of Mountainview Church. They may be published or used for any application in newspapers, videos, posters, slide presentations, FaceBook, YouTube, other social media and networking sites or otherwise displayed to the public—either in whole or in part by Mountainview Church.

Release and Waiver of Liability

In consideration of me/my child being permitted to enter the Mountainview Christian Reformed Church (hereafter Mountainview CRC) property, and being permitted to participate in Mountainview CRC activities and events, AGREE TO WAIVE, RELEASE, DISCHARGE AND COVENANTS NOT TO SUE, its employees, officers, directors, servants and agents from all liability to the child, to myself, or any personal representative of either, assigns, heirs, and next of kin, for any and all claims for damages, for death, personal injury or property damage, suffered by me or my child while participating in any Mountainview CRC event or activity. I/WE UNDERSTAND THAT THIS RELEASE AND WAIVER OF LIABILITY applies to any claims occurring from injury to person or property, whether caused by negligence of Mountainview CRC or otherwise. I/We acknowledge that the intent of this RELEASE AND WAIVER OF LIABILITY is to prevent Mountainview CRC from being held liable for injuries to person or property, and that selecting YES constitutes my/our agreement and the agreement, not to hold Mountainview CRC responsible for any damages, losses, injuries to person or property, as a result of any negligence or other wrongful conduct on the part of Mountainview CRC or on the part of other third parties. I/We ALSO AGREES TO INDEMNIFY AND HOLD HARMLESS Mountainview CRC from any loss, liability, damage, or cost that Mountainview CRC may incur due to the presence of myself or said child, upon Mountainview CRC premises or in any way using any of Mountainview CRC facilities or attending any events of Mountainview CRC, whether caused by negligence of Mountainview CRC or otherwise. FURTHER, I/WE EXPRESSLY AGREE THAT THIS RELEASE AND WAIVER OF LIABILITY is intended to be as broad and inclusive as is permitted by the law in the Province of Ontario. If any portion is held to be invalid, it is agreed that the balance shall continue in full legal force and effect. I/We further agree that this Release and Waiver of Liability shall be valid for the program season or year. I/We have read and voluntarily agree, and further acknowledge that no oral representations, statements, or inducements apart from the written agreement have been made.

Yes, I agree

No, I do not agree