* Student Name
Student Email Address
Only list if this is a cell phone your student will have on the trip.
* Parent/Guardian Name
Relationship to Student
Health Information Section
Please complete honestly and to the best of your ability.
Please provide any additional information about the individuals health that you think important or that may affect the individual's ability to fully participate in the Road Trip 2018.
Permission to Treat Authorization
I hereby give permission to the leaders of East Coast Church to provide routine health care; to administer prescribed medications; and to administer emergency treatment for me/my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for me/my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes. If the person named herein is a minor, it is my intention that representatives of East Coast Church be considered "personal representatives" for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to ECCC representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in activities; and if the person named herein is a minor, to provide information to the ECCC representatives to keep me informed of my child's health situation. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the ECCC leaders to secure and administer treatment, including hospitalization, for the named person.
By checking this box, I am agreeing to the release statement above and accept this as my digital signature.
Release of Liability and Assumption of Risk
I, the undersigned, am a 'Participant' in "Road Trip 2018" or I am the parent /legal guardian of the person above, who is, with my permission, a 'Participant' in the "Road Trip 2018" program, sponsored by East Coast Community Church, and others for my benefit.
In consideration of being allowed to participate in any way in the program, related events and activities, I the undersigned, acknowledge, appreciate and agree that:
I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED IN THE ROAD TRIP 2018 ACTIVITIES INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns hereby agree to hold East Coast Community Church and its officers, agents, trustees, land owners, sponsors, volunteers, and employees harmless from and against any and all liabilities, actions, causes of actions, claims, expenses, and damages suffered on account of any injury to me or my property, even injury resulting in death, which I now have or which may arise in the future in connection with my participation in the activities or any activities, acts, or events associated therewith, including but not limited to any transportation provided or involved in such activities. I expressly agree that this release agreement is intended to be as broad and inclusive as permitted by the laws of the State of Florida and that if any portion of this Release is held by any court of competent jurisdiction to be invalid or unenforceable, it is agreed that the balance of the Release shall, notwithstanding, continue in full legal force and effect. This Release contains the entire agreement between East Coast Community Church and me or East Coast Community Church and the participant, that I am the legal guardian of, and the terms of this Release are contractual and not mere recital.
Many of the related activities provide desirable experiences that are accompanied by inherent risk that are often higher than normal daily life risks.
I am aware and understand that participating in activities while on "Road Trip 2018", including, but not limited to, use of water activities, jet skis, theme parks, tubing behind jet ski, snorkeling, snuba or swimming in the river, ocean, or swimming pool, Paintball, riding in a boat or Airboat in the river or ocean, wilderness activities, field sports, and all other camp related activities including work related activities, include the potential risk of injury or death. Some of these risk include (but are not limited to), accidents with fire arms, accidents related to swimming, boating or water sports, including drowning, attacks from wildlife in the water and on land, transportation accidents, physical strain related to strenuous field games and work related accidents for volunteers and paid employees.
I understand that it is normal for participants of this nature including East Coast Church to utilize volunteer staff and staff that is under 18 yrs. old and that these staff members may not have extensive professional training. While East Coast Church attempts to provide adequate instruction, policies and procedures, there are inherent risk involved with participating in activities and events that include supervision and oversight by non-professional staff members. Some of the risk include injury or death that may be a result of the staff members oversight of potential hazards, lack of judgment in analyzing risk, lack of proper judgment in prevention of risk and other negligent (but not grossly negligent or intentionally wrong) acts.
I also am aware and understand that all of the program activities are strictly voluntary and it is my choice to participate in each activity to whatever degree I deem appropriate, after due consideration of the risks, my own physical health, physical abilities and medical condition.
I agree that I am solely responsible for my own participation and for my own physical and emotional well-being. I will not be under the influence of any chemical substance, including alcohol, while participating. The health history presented to East Coast Church is correct to the best of my knowledge.
I willingly and knowingly assume for myself, my heirs, family members, executors, administrators, and assume all risk of physical injury and emotional upset which may occur during or after participating in any aspect of the program and to hold East Coast Church, the Ministry, its sponsors, Land owners, its employees, its volunteers, its instructors, facilitators and agents and participants harmless for any liability arising out of my participation in the program. Should East Coast Church or anyone acting on their behalf of, or in connection with, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify (to shift the responsibility for payment of damages to someone else) and hold East Coast Church and its sponsors, Land owners, its employees, its volunteers, its instructors, facilitators and agents and participants harmless for all such fees and costs.
I authorize East Coast Church to have and use photographs, slides and videotapes of the person named above as needed for its records and marketing purposes.
Unacceptable Behavior Agreement
If my student behaves in a fashion that requires their involvement in The Road Trip 2018 to be terminated, I agree to pick them up within 4 hours of notification from East Coast Leaders. While grace and leniency will be extended to students for moments where they simply lacked better judgment, the following actions will be grounds for immediate dismissal from The Road Trip 2018: drug use, possession of firearms or weapons, sexual misconduct, theft and criminal activity. If I cannot pick up my student within 4 hours, I agree to cover all expenses incurred by East Coast Church to transport my child home.
Thank you! Your online registration has been successfully submitted.
Payments can be made through our online payment registration page:
Your pricing is based on when your $100 deposit is made.
*payments can also be made by using giving stations on Sunday morning and clearly identifying the student being credited.