LIABILITY RELEASE FORM

 

RELEASE OF ALL CLAIMS

         

 In consideration for being accepted by _______________________________________ for participation in

 

___                                          ___________________, we (I), being 21 years of age or older, do for our

               (Name of trip or activity)

 selves (myself) (and for and on behalf  of my child-participant if said child is not 21 years of age or older) do hereby release , forever discharge  and agree to hold harmless                                                       and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above-described trip or activity.

                Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 21 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

                Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant

                The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

               

(If the participant has not attained the age of 21 years):

                We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in said trip, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.

                Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

 

_______________________________________                                   (Only participant need sign if 21 years of age or

  (Type or print name of participant)                                                    older.  If under 21, both parents must sign unless

                                                                                                                   parents are separated or divorced in which case

_______________________________________                                     the custodial parent must sign.)

(Parent(s) telephone)

 

_______________________________________                                     _______________________________________

(Pastor’s telephone)                                                                                 Father                                                 Date

 

Hospital Insurance__ Yes__ No

Insurance company

_______________________________________                                     _______________________________________

Address________________________________                                  Mother                                               Date

_______________________________________

_______________________________________

Policy number___________________________

Physician_______________________________                    _______________________________________

Physician’s phone_______________________                                    Legal guarding                                   Date

Emergency phone numbers________________          

_______________________________________                                 _______________________________________

_______________________________________                                    Participant, If age 21                        Date

 

TRIP PARTICIPANT ONLY 

                I have read the foregoing and understand the rules of conduct for participants and will abide by them as well as the directions of the leadership of the trip.

 

                                                                        ______________________________________

                                                                          Participant                                            Date