Youth Release Form 2026-2027

This is the general release form for minors participating in events sponsored or coordinated by Leesburg United Methodist Church and Harmony United Methodist Church, whether held onsite or offsite

Parent/Guardian Name

This address will receive a confirmation email

Phone

Address

Emergency Contact Name

Emergency Contact Phone

Youth Name

Date of Birth

Grade Fall 2026-27

Does your child have any Medical or Allergy concerns you need to share?

Yes No

Medical Information (Please include any pertinent information, should medical assistance be required.)

Photo Release: Leesburg UMC and Harmony UMC has my permission to use my or my child’s photograph publicly to promote LUMC/HUMC Youth Ministries. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Yes No

Health Guidelines Info: I will follow the LUMC Health guidelines that are in place for any given event or activity that I participate in and I understand that these are updated regularly and it is my responsibility to watch for such updates.

I will

Type your name below as your digital signature. Under the terms of this Agreement and sufficiency of which is hereby acknowledged, do hereby release and forever discharge Leesburg United Methodist Church and Harmony United Methodist Church including their agents, employees, successors and assigns, and their respective heirs, personal representatives, affiliates, successors and assigns, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, none of whom admit any liability to the undersigned, but all expressly denying liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, which I now have or may hereafter have, arising out of or in any way relating to any and all injuries and damages of any and every kind, to both person and property, and also any and all injuries and damages that may develop in the future, as a result of or in any way relating to participating in church sponsored or promoted events and activities. It is understood and agreed that this Agreement is made and received in full and complete settlement and satisfaction the causes of action, claims and demands mentioned herein; that this Release contains the entire Agreement between the parties; and that the terms of this Agreement are contractual and not merely a recital. Furthermore, this Release shall be binding upon the undersigned, and his respective heirs, executors, administrators, personal representatives, successors and assigns. This Release shall be subject to and governed by the laws of the State of Virginia. This Release has been read and fully understood by the undersigned and remains in effect until June 30, 2027

Youth Release Form 2026-2027

Description

Please Fix the Following