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_______________________________________________ has my permission to attend the Aurora Cluster UMC Youth Fellowship Lock In, Friday, June 20th 8PM-Saturday, June 21st 6AM, 2008. I will provide transportation for my participant to Rush Copley Healthplex, Aurora, IL. I understand that participation is voluntary and that _______________________ will follow the rules of the Youth Fellowship UMC covenant for behavior and conduct. Because of the nature of the events (swimming, rock climbing, recreational activities), I understand that the UMC is not responsible for injuries that may occur during participation. I also confirm that in the event of injury, medical expenses are the responsibility of the parent/guardian the UMC is not responsible for medical expenses. During the event I can be reached at_________________________________. If I am unavailable please call__________________ at __________________.

Signature of Parent/Guardian

Date

For information on Rush-Copley Healthplex visit: http://www.rushcopley.com/consumer/rchealthplex/index.aspx

Rush-Copley Waiver Of Claims ________________________________________________________________________________ Print Participant’s Name __________________________________________________________________________________________________ Address City State Zip ________________________________________ Phone

________________________________________ Print Child’s Name (if applicable)

Waiver of claims: It is expressly agreed that individuals using the Rush-Copley Healthplex Fitness Center’s facilities, participating in RCHFC sponsored activities, programs, or events provided by RCHFC and its affiliates, and their directors, officers, employees, agents, independent contractors and representatives, shall not hold the Rush-Copley Healthplex liable for any injuries or any damage to any member or guest, or for the property of any member or guest, or be subject to any claim, demand, injury or damages resulting from acts or omissions or passive or active negligence on the part of RCHFC and its affiliates, and their representatives arising from the member’s or guest’s use of RCHFC. The member or guest for himself/herself, and on behalf of his/her executors, administrators, heirs, assigns, successors, next-of-kin, affiliates and their representatives, excludes the Rush-Copley Healthplex from all such liabilities, claims, demands, injuries, damages, right of action or cases of action whether the same be known or unknown, anticipated or unanticipated. RCHFC and its affiliates and their representatives shall not be responsible for or liable to members or their guests for articles damaged, lost or stolen in or about RCHFC, or in the lockers, or for loss or damages to any property, including but not limited to, automobile and the contents thereof. Without limiting the scope of the above waiver of claims, the member or guest does hereby declare himself/herself to be physically sound, having medical approval in the activities and ability to use the facilities of RCHFC. ____________________________________________________________________ Signature of Guest Date ___________________________________________________________________ Signature of Parent/Guardian of Child Date

Lock-In Permission Slip  

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