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.

I acknowledge it is my responsibility to ensure that myself and the minor listed above engage in all safety measures suggested or required by the Centers for Disease Control (CDC) and applicable local ordinances or state law concerning COVID-19. In addition, if at any time I believe that conditions are unsafe or that the minor listed above is unable to participate due to physical or medical conditions, then I will immediately discontinue their participation. I understand that despite diligent hygiene measures and compliance with the law, there is no guarantee that infectious transmission will not occur.

I understand symptoms of COVID-19 include:

  • Fever
  • Fatigue
  • Dry Cough
  • Difficulty Breathing

Screenings will be conducted upon arrival and on each day of the event. I understand that the following must be true statements concerning the minor listed above at the start of the event and will not permit the minor listed above to attend if any of the following are not true when the event begins:

  • I understand the above symptoms and affirm that the minor listed above, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
  • I affirm that the minor listed above, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.
  • I affirm that the minor listed above, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days.
  • I affirm that the minor listed above, as well as all household members, have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the past 30-days.
  • I understand that Christ In Youth cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant in Christ In Youth events.
  • I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
  • I further acknowledge that Christ In Youth cannot guarantee that the minor listed above will not become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by the COVID-19 may result from the actions, omissions, or negligence of myself, the minor listed above and others, including, but not limited to, Covered Parties and other participants engaged in Christ In Youth activities and their families.

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.