Please provide the following details for your child.

The undersigned represents to VALLEY BROOK COMMUNITY CHURCH, that he/she does hereby consent to child taking part in the noted activity, with full understanding insofar as such activity will involve mingling with individuals and groups, that there is always the risk of injury, illness, loss and possible consequent expense for medical, diagnostic and curative treatments, and incidental loss and expense, and the undersigned does for him/herself assume the risk of such an expense, and does hereby wholly release VALLEY BROOK COMMUNITY CHURCH from any responsibility of liability; and waives any claims or cause of action against it or its agents that might arise on account of loss, injury or expense occasioned by any sort of accident or any other circumstance involving him/herself, and agrees to hold harmless and/or indemnify VALLEY BROOK COMMUNITY CHURCH in event any such claim should arise, except in the situation of gross negligence on the part of VALLEY BROOK COMMUNITY CHURCH or its agents.