Cornerstone Chapel

Permission Form

Participant’s Full Name:
Outreach Activity:  
Activity Start Date:
Activity End Date:

I, myself, or the undersigned parent and/or guardian of said youth, give permission for said youth to participate in all of Cornerstone Chapel’s Youth events for the years of 2020-2021. This would include activities in the building, activities on the property, activities off-site and transportation to and from events. I am confident that the adult leaders and sponsors will take appropriate care of my child and every effort will be made for his/her safety. However, I understand that accidents do occur; and, in the event of an emergency, every effort will be made to contact me. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any medical or dental treatment and care deemed necessary by medical personnel.

In the event of a minor illness or injury (cold, headache, scrape, cut, sprain, etc.), I authorize the staff or medical personnel to make common remedies such as (check appropriate medication):


I, myself, or the undersigned parent and/or guardian of said youth, do release, acquit, discharge, and covenant to hold harmless and indemnify Cornerstone Chapel, its representatives, its volunteers and its activity leaders from any and all actions, damages, and liabilities arising out of any accident or sickness, or treatment thereof, incurred by said youth during the minor’s participation in Cornerstone Chapel programs or activities available to me or my child in dosages appropriate for his/her age, and to clean, bandage, or wrap wounds as necessary. I understand the risks associated with these over the counter medications.

I agree to allow Cornerstone Chapel to use any photographic image of the minor taken while participating in the activity. These images may be used in promotions or other related marketing materials.

In the event of any dispute or disagreement between parties listed with respect to this agreement, each party shall appoint a representative whose task it will be to meet with the representative appointed by the other party for the purpose to resolve any dispute.  No legal action regarding the dispute may take place until either one of the two representatives concludes in good faith that a resolution does not appear likely.  At that time, the dispute shall be settled only by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, (complete text of the Rules is available at In that case, Judgment upon an arbitration award may be entered by any court having competent jurisdiction, in conformity with the laws of the Commonwealth of Virginia.

I understand and acknowledge that, under the Uniform Electronic Transactions Act, by proceeding to register online and by signing this waiver electronically, such electronic registration and electronically signed Waiver will be valid and enforceable in the same manner as a hand-signed document that exists in physical form and that a record or signature may not be denied legal effect or enforceability under law solely because it is in electronic form.

I have read the above information; and, by signing here I give my authorization, dated June 19, 2024.

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Signature Certificate
Document name: Permission Form
lock iconUnique Document ID: b96006132837b6d0e9940392c43409105df19d1c
Timestamp Audit
February 10, 2020 12:19 pm EDTPermission Form Uploaded by Cornerstone Chapel - IP