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  • Parent/Guardian Contact Information

  • I recognize that the organization to which this application is being submitted is relying on the accuracy of the information contained herein. Accordingly, I attest and affirm that all of the information that I have provided is absolutely true and correct.

    I authorize the organization to contact any person or entity listed in this application, and I further authorize any such person or entity to provide the organization with information, opinions, and impressions relating to my background or qualifications.

    I voluntarily release the organization and any such person or entity listed herein from liability involving the communication of information relating to my background or qualifications. I further authorize the organization to conduct a criminal background investigation if such a check is deemed necessary.

    I have carefully read the policy and procedures of the organization, and I agree to abide by them and to protect the health and safety of the children or youth at all times.

    Liability Release: I, and my heirs, in consideration of my participation in activities at Show-Me Christian Youth Home, herby release Show-Me Christian Youth Home, including the Board of Directors, its officers, employees and agents, and any other people officially connected with this entity, from any and all liability for damage to or loss of personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money, which might occur while participating in my physical condition, for the condition or selection of course route and for the presence or actions of any other participants. I am aware of the risk of participation, (which includes, but is not limited to, the possibility of sprained muscles and ligaments, broken bones and fatigue). I hereby state that I accept responsibility for the activity which I choose to engage in. I understand that participation in any activity is strictly voluntary and I freely chose to participate. I understand Show-Me Christian Youth Home does not provide medical coverage for me. I verify that I will be responsible for any medical cost I incur as a result of my participation. I hereby certify that this information is true and complete to the best of my knowledge.

  • Date Format: MM slash DD slash YYYY