LIABILITY FORM Please complete by June 1, 2021 Today Date Format: MM slash DD slash YYYY Name of Participant* First Last Date of Birth* MM DD YYYY Name of Parents (or legal guardian or custodian) of Minor Participant* First Last Liability Release*I, the undersigned adult participant and/or parent/legal guardian of the above named minor participant for myself and/or such minor, our heirs, personal representatives, assigns and next of kin, request permission to participate in the following event, organized and/or conducted by the theChapel of Pinellas, Inc. which event shall include the use of the property, facilities, transportation and other services provided by or on behalf of the theChapel of Pinellas, Inc. or third parties attendant with such event: theChapel Internship 2021. Collectively, such event and the use of the property, facilities, transportation and other services provided by or on behalf of the theChapel of Pinellas, Inc. or third parties attendant with such event shall be referred to as the “Activity”. In consideration for theChapel of Pinellas, Inc. to permit my and/or such minor’s participation in such Activity, and intending to be legally bound, I, individually and on behalf of such minor, do hereby: 1. Agree to observe and obey and instruct such minor to observe and obey all written rules and warnings and any oral instructions or directions provided by theChapel of Pinellas, Inc., or the employees, representatives or agents of theChapel of Pinellas, Inc. 2. Recognize that there are certain inherent risks associated with the Activity, including, without limitation, risks attendant with interaction with other participants, travel and exposure to nature and the elements and for myself and/or on behalf of such minor assume full and complete responsibility for all risks including, but not limited to risks of i) serious personal injury or death to myself and/or such minor, and ii) serious damage to my property and/or the property of such minor. 3. Release theChapel of Pinellas, Inc., its employees, agents, representatives, successors and assigns (collectively, “theChapel of Pinellas, Inc.”) of and from any and all liabilities, costs, obligations, causes of action, demands and/or claims of any nature whatsoever, whether arising at law or in equity, I and/or such minor may have or may hereafter have, against theChapel of Pinellas, Inc. by reason of any matter, cause or action arising from the Activity and further to protect, defend, hold theChapel of Pinellas, Inc., harmless and to indemnify theChapel of Pinellas, Inc. against claims, damages and liabilities, including without limitation, reasonable attorney fees and costs, incurred by theChapel of Pinellas, Inc. in connection with or arising out of my and/or such minor’s participation in the Activity. This release and indemnification shall specifically survive the termination of the Activity and for any applicable statute of limitations periods under which a claim may be brought thereafter. 4. Represent that I have legal authority over and custody of such minor. 5. Understand the Activity may be conducted at some distance from available medical assistance. In case of illness or injury to such minor, I understand that reasonable effort will be made to contact me or any other designated parent/legal guardian of such minor and in case of a medical emergency, 911, if available, will be called. In the event that I or any other parent/ legal guardian cannot be notified or are not available, I authorize theChapel of Pinellas, Inc. designated Activity supervisor to provide first aid treatment and consent to appropriate additional medical treatment or attention as may be required by the circumstances, for such minor (and myself if I am participating in the Activity and unable to provide informed consent for myself) , including without limitation, diagnostic tests, anesthetic and surgical procedures, admission to hospital care and such other medical treatment as determined to be reasonably necessary and appropriate by a licensed healthcare provider, including any first responder and/or physician. I understand that theChapel of Pinellas, Inc. provides no insurance which will cover me or such minor in conjunction with the Activity or in conjunction with any provided medical care and I agree to be fully responsible for any medical treatment costs provided to me and/or such minor. I maintain accident and health insurance for myself and such minor. I agree to the Terms of Service Medical InformationPlease list all pertinent medical information (for example, allergies, medications, physical impairments, or any other information necessary for a healthcare provider). Explain fully.Student Signature*Parent/Guardian Signature of Minor Participant.To be completed if a student is under the age of 18 before June 1, 2021.