Consent and Liability Release Form

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Participant Name *

First

Last

Age *

Birth Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Phone Number *

Parent/Guardian Name *

First

Last

Parent's Email *

Parent/Guardian Name *

First

Last

Parent's Email *

Student Email *

Work Phone *

Cell Phone *

Work Phone *

Cell Phone *

TO WHOM IT MAY CONCERN:

The undersigned do(es) hereby give permission for our (my) child(ren): *

First

Last

to attend and participate in (event) *

from (dates) *

Medical Insurance *

Yes No

Insurance Company *

Policy/Group I.D# *

Allergies or Medical Conditions *

Emergency Phone Numbers in case Parent/Guardian cannot be reached *

Parent/Guardian Signatures *

First

Last

Parent/Guardian Signatures *

First

Last

Date *

I have read and agree with the following 4 statements. *

yes, and I will type my name in the box below

1. LIABILITY RELEASE: In consideration of New Song Church’s allowing the Participant to participate in youth ministry activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless New Song Church, its directors, employees, volunteers and agents (collectively herein the “Church”) 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 youth Participant while involved in the youth activities, other than in incidents considered to be gross negligence. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, we (I) [and on behalf of our (my) minor youth-Participant(s)] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein, other than incidents considered to be gross negligence. 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 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. 2. MEDICAL TREATMENT PERMISSION: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization. 3. EARLY RETURN HOME POLICY: Should it be necessary for our (my) youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. 4. TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for our (my) youth to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by New Song Church. My youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation. *

Submit

LIABILITY RELEASE: In consideration of New Song Church’s allowing the Participant to participate in youth ministry activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless New Song Church, its directors, employees, volunteers and agents (collectively herein the “Church”) 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 youth Participant while involved in the youth activities, other than in incidents considered to be gross negligence. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises.
Furthermore, we (I) [and on behalf of our (my) minor youth-Participant(s)] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein, other than incidents considered to be gross negligence.
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 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.

MEDICAL TREATMENT PERMISSION: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for our (my) youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for our (my) youth to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by New Song Church. My youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation.

Consent and Liability Release Form

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