LS STEM Indemnity Form

Student

Student Name(Required)

First Last

Email(Required)

Age(Required)

Under 18

Over 18

Today's Date(Required)

Confirmation(Required)

I hereby confirm that of my own free will, I am participating in the Program and subsequent outreaches or any extended period agreed to by both parties. I also confirm that I am aware of possible risks that may lie ahead, I hereby give full indemnity for any claims of whatsoever, that may result from ministry participation and other social activities, to the organizers thereof and the Program.

Witness 1

Witness Name(Required)

First Last

Confirmation(Required)

I am witness to and acknowledge the indemnity confirmed by the above mentioned.

Witness 2

Witness 2 Name(Required)

First Last

Confirmation(Required)

I am witness to and acknowledge the indemnity confirmed by the above mentioned.

Parent/Legal Guardian

NOTE: If under the age of 18, the signature of a parent or guardian is required. (Legal guardian) If parents are divorced and applicant is under 18, then both parents need to sign.

Parent's Relationship(Required)

Divorced

Not Divorced

Name of Parent(Required)

First Last

Confirmation(Required)

I, the legal guardian, hereby agree to and acknowledge the indemnity confirmed by the above mentioned.

Name of Parent 2(Required)

First Last

Confirmation(Required)

I, the legal guardian, hereby agree to and acknowledge the indemnity confirmed by the above mentioned.

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