Youth Kickball Day 2025 Consent Form

Event Information

I authorize my child (undersigned) to attend the Youth Kickball Day at Victory Park, Pasadena, which will take place on Saturday, May 17th, from 10am to 3pm.  Parent(s) or Guardian(s) are responsible to drop-off and pick-up their youth at the park.

Child Information

Parent Information


Emergency Contact

Authorization of Consent for
Treatment of a Minor

a minor, do hereby authorize Calvary Chapel Pasadena, its staff or representatives, as agent(s) for the undersigned to consent to an x-ray examination, anesthetic. medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act on the Medical Staff of any hospital or medical clinic whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment of hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.

This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. (Allows Parent(s) or Guardian to authorize any adult to consent to medical or dental treatment as stated in paragraph No. 1 above.)

This authorization shall remain effective on May 15th, 2025, from 10am to 4pm, unless sooner revoked in writing delivered to said agent(s).

Insurance Information

Patient Medical History Information

For patient's protection
1) Allergies and Sensitivities: Is there a history of skin or other outward reaction
or sickness following injection or oral administration of:










2) Drugs taken recently: Within the past six (6) months has the patient taken:






Calvary Chapel Pasadena Release, Waiver
& Indemnity Agreement

It is the intention of (Parent or Guardian of Child/Minor) by this agreement
to exempt and relieve Calvary Chapel Pasadena and its officers, agents, servants or employees from liability for personal injury, property damage or wrongful death of (the Child/Minor) (Name of the Minor hereafter referred to as the Child / Minor): caused by any act of Negligence of Calvary Chapel
Pasadena and its officers, agents, servants or employees.

For and in consideration of permitting (the Child/Minor) to observe, or use any facility or equipment of Calvary Chapel Pasadena or Park Facility, or engage in and/or receive instruction in any activity or activity incidental there
to some of which may involve dangers and risk of bodily injury, beginning on
until , the undersigned parent and /or guardian of (the Child/Minor) hereby
voluntarily and absolutely releases, discharges, waives and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage or wrongful death occurring to (Name of Minor) as a result
of (the Child / Minor)’s observing or using facilities or equipment of Calvary Chapel Pasadena, or engaging in or receiving instructions in any activities some of which may involve dangers and risk of bodily injury or in activities
incidental there to wherever or however the same may occur, and for whatever period said activities or instructions may continue.

By agreeing parents are giving permission for their child in the aforementioned event that they might participate in the following activities: (Obstacle Challenge, Basketball, Football, Dodge Ball).

The undersigned parent or guardian of (the Child/Minor) for him/herself, his/her heirs, executors, administrators or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be
prosecuted against Calvary Chapel Pasadena or its officers, agents, servants or employees, the undersigned parent or guardian will indemnify and hold harmless Calvary Chapel Pasadena and its officers, agents, servants
or employees from any and all claims or causes of action by (the Child/Minor) or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of (the Child/Minor) present any claim against Calvary Chapel Pasadena and said per-sons for personal injuries, property damage, wrongful death or otherwise, caused by any act of negligence by Calvary Chapel Pasadena and said persons.

The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the
observation, activities or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release.
The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

CFC010720
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