Instructions

Please fill out all fields and sign at the bottom. Use your mouse to draw your signature, or if you have a touch screen, use your finger. The form will not allow you to submit without information in all fields. If there is a field that does not apply to you, please write N/A. Once you hit submit, a copy of this form will be sent to CIY and emailed to the Leader in charge of your group, as well as to you. If you have trouble with this form or questions, please contact CIY at 417-781-2273. Javascript must be enabled to fill out the form. Error Code: 2290.


Note: Please use 2 digits. ex: 09

Parent/Legal Guardian Contact Info:

Emergency Contact
(Other than Parent listed above)


I, the participant or for those under 18 the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in this Christ In Youth Program. The individual identified on this form understands that all participants are required to abide by the Program rules and be directly responsible to the Christ In Youth Program Director. The Christ In Youth Program Director assumes responsibility for discipline at the Program and, if necessary, may, because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for returning the participant home.

Further, I hereby release and forever discharge a) Christ In Youth and its directors, officers, employees, Program Directors, agents and all other persons or entities acting on their behalf (the “Covered Parties”) and b) the lessor/owner of properties on which the Programs are held, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the participant, the undersigned, and/or any member of the participant’s family by reason of participating in any activities associated with Christ In Youth Programs WHETHER OR NOT SUCH CLAIMS, ACTIONS, DEMANDS, LIABILITY, COSTS OR EXPENSES ARE CAUSED BY THE NEGLIGENCE OR OMISSION OF ANY OF THE COVERED PARTIES.

Further, I hereby agree to indemnity and hold harmless a) Christ In Youth and its directors, officers, employees, Program Directors, agents and all other persons or entities acting on their behalf (the “Covered Parties”) and b) the lessor/owner of properties on which the Programs are held, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the participant, the undersigned, and/or any member of the participant’s family by reason of participating in any activities associated with Christ In Youth Programs WHETHER OR NOT SUCH CLAIMS, ACTIONS, DEMANDS, LIABILITY, COSTS OR EXPENSES ARE CAUSED BY THE NEGLIGENCE OR OMISSION OF ANY OF THE COVERED PARTIES.

Further, I do authorize the minister or sponsor of the Program, or any Christ In Youth staff member to take the participant to a doctor or hospital and I hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and I hereby assume financial responsibility for all expenses incurred for such treatment and, if necessary, all expenses to return the participant home.

Further, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of the participation in this Christ In Youth Program. I hereby release and agree to hold harmless and indemnify the Covered Parties, for any liability and/or expense sustained as the result of negligent, willful or intentional acts of the participant, including damages to the Program facility and/or keys not returned at the time of group checkout. I agree to pay for keys not returned at time of group checkout or damage done to any Program facility or Christ In Youth property by the participant.

For valuable consideration received, I hereby irrevocably grant to Christ In Youth, Inc. the worldwide, royalty-free, right to use the participant’s name, voice, likeness, and image in all forms and media, and in all manners for any lawful purposes, commercial or noncommercial. I understand that my participation makes me eligible to receive educational information and updates regarding ministry successes and opportunities.

I acknowledge this agreement is intended to be as broad and inclusive as permitted by the laws of the state of Missouri and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further agree this agreement will be governed by and construed in accordance with the laws of the State of Missouri without giving effect to the principles of conflict of law and the courts within Missouri will be the only courts of competent jurisdiction. I hereby irrevocably submit to the personal jurisdiction of the courts of Jasper County, Missouri.

If any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further agree this agreement will be governed by and construed in accordance with the laws of the State of Missouri without giving effect to the principles of conflict of law and the courts within Missouri will be the only courts of competent jurisdiction. I hereby irrevocably submit to the personal jurisdiction of the courts of Jasper County, Missouri.

I hereby certify that I have carefully read the foregoing and acknowledge that I understand and agree to all of the above terms and conditions


Draw your signature | Clear

Draw your signature | Clear



I understand and acknowledge that this form is being submitted electronically. Further, I attest that the signature affixed here is that of the person named as the parent or legal guardian of the participant named herein (for those under 18) or of the participant named herein (for those 18 and over). My signature on this form transmitted in electronic format shall be treated as an original signature in all purposes. I understand that this electronic form is legally binding as if submitted as a physically signed original.