This completed form is active at any time the above noted child is attending activities associated with Koinos Community Church - Sinking Spring, PA. I understand that every effort will be made to protect the well being of my child, but agree in the case of accidental injury, I will hold Koinos Community Church and the adult leaders of the event harmless from any damages.

In the event that my child would need emergency medical treatment, I give permission for the adults in charge of the group to secure the necessary treatment to protect the life and health of my child. I understand that I will be contacted before any medical treatment is begun except where a delay in treatment would not be in the best interest of my child.

Additionally, I understand that as a participant of activities, my child may be photographed or videotaped and that either medias may be used in Koinos related presentations or promotional materials, as well as on both the church website and Facebook page. Personally identifiable information of these participants (name, address, etc.) will not be used. I release Koinos Community Church from any and all liabilities.