Element Release Form



Highpoint Church (the “Church”) is organizing or planning a certain event or activity generally described as Element (the “Event”).  I wish for my child to participate in the Event. 



1. PARTICIPANT, PARENT (Legal Guardian) INFO SECTION: Fill out all information below.

2. RELEASE & CONSENT SECTION: Carefully read each detail.

3. SUBMIT: When you press the SUBMIT button you are agreeing to all details of the RELEASE & CONSENT SECTION and acknowledging that all PARTICIPANT & PARENT info is correct.


First Name*
Last Name*
Date of Birth *
Grade Level*
Street Address*
Parent/Guardian Name*
Parent/Guardian Phone Number*
People authorized to drop off or pick up from the event:
Emergency Contact (Name & Phone Number)*
Do you health insurance?*
Primary Insurance Name*
Primary Insurance Policy #*
Insurance Phone *
Any activity restrictions?*
Will the participant be bringing any medication(s) with them?*
If yes, are there any special instructions?*
List all medications the participant will be bringing with them.*
Copy of Insurance Card
Signature of Parent or Legal Guardian*
Parent/Guardian Email*
Please answer the simple math question below to submit the form.
2 + 2 =


I acknowledge and agree to the following:

1. My Child (the participant above) may participate in the Event.

2. I certify and affirm that I have been completely and thoroughly informed that as a youth participating in the Event at Highpoint Church, my child will participate in certain activities which carry with them a degree of risk and danger as children are sometimes injured during these types of activities. I recognize and acknowledge that these risks and hazards may result in serious physical injury, sickness, or death, and damage to, loss, or destruction of property, and no guarantee can be made that Highpoint Church or others can provide assistance if any of the foregoing result.

3. If my Child is injured or needs medical attention while participating in the Event, I give the Church, its employees and volunteers, permission to seek medical diagnosis and treatment which in their best judgment they deem to be necessary or appropriate under the circumstances. 

4. In cases of emergency, I further consent to the examination or treatment of my child by a physician duly licensed to practice medicine in the State of Tennessee or the relevant state or any health care professional duly licensed to provide health care services in the State of Tennessee or the relevant state for medical care and services deemed necessary by Highpoint Church, its agents, servants, and employees. I understand and acknowledge that Highpoint Church will not have any obligation to try to provide medical assistance between the time of an injury and the time that a medical professional is available to provide treatment, but I hereby authorize Highpoint Church, through its employees and volunteers to take any action they deem appropriate to render aid to my Child and waive any potential claim that my Child may have concerning any further injury and/or harm caused by such employee or volunteer through their good Samaritan actions.

5. I give permission to the Doctor or health care professional to provide any and all medical care they deem, in their professional opinion, to be necessary.  

6. I agree to pay for any and all medical expenses incurred as a result of the use of this consent.

7. I understand that there are inherent risks associated with a number of activities that my child will be doing associated with the ministry at Highpoint and that it is not uncommon for a child to sustain an injury in group activities like this one due to no fault of anyone.  In consideration for my child being allowed to participate in activities sponsored by Highpoint Church, I release Highpoint Church, its directors, officers, employees, agents, and all volunteer personnel from any and all liability for personal injuries and/or damage(s), injury, or illness that may be suffered by the children listed below for any such injury unless such injury is the result of clear negligence on the part of Highpoint Church.  Moreover, if a volunteer or employee of Highpoint Church engages in grossly negligent, reckless or intentional conduct unbeknownst to the leadership of the church that results in injury to my child, I understand that I will be able to pursue a claim on behalf of my child against that individual and against the church if I can prove that it was aware of this grossly negligent, reckless or intentional conduct and did nothing to stop it. I/we further agree to release and hold harmless Highpoint Church, its directors, officers, employees, agents, and all volunteer personnel for any claim and/or damages relating to any above described type accidental injury (that does not fit into one of the above categories) as a result of any such injury or damage including reasonable attorney fees, litigation expenses, or court costs. This release is not an attempt to prevent the undersigned parent from pursuing a claim for negligence against the church or its agents where there is a good faith basis for doing so.

8. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

9. I consent to the use of my child’s photograph, likeness, image, voice or performance on the Church’s internet website, social media, CD or DVD labels, video tape or film clips, advertisements or other official Church publications at the sole discretion of the Church and to be used in whole or in part of any and all broadcasting, audio/visual, and/or exhibition purposes in any manner or media, in perpetuity, throughout the world.

10. I have fully informed myself of the contents of this PARENTAL AUTHORIZATION, CONSENT AND RELEASE by reading it before I signed it.

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