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Permission & Liability Release Form
Permission & Liability Release Form
Ministry or Department Responsible for Activity
Rooted Student Ministries
Date(s) of Activity
Participant Date of Birth
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Emergency Contact 1
Emergency Contact 2
Last TETANUS shot
List any allergies this participant may have
Specify any Medications that must be administered
We (I), being 21 years of age or older, do for ourselves (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 to hold harmless Kings Point Church of God 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 activity. Furthermore, we (I)and on behalf or our (my) child-participate if under the age of 21 years) hereby assume ail 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 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 older. If under 21, parents must sign unless parents are separated or divorced in which case the custodial parent must sign.)
I certify that I have been informed that, as a member of the Kidz Zone my child will be participating in a number of activities for this event, which carry with them a certain degree of risk. I consent for my child to participate in these activities: I also represent that my child is physically fit and has the necessary skills to safely participate in these activities.
Medical Treatment Authorization
The purpose of the form is to make it possible for parents and / or guardians to authorize the provision of emergency treatment for minors who may become ill or injured on a trip or activity. You can authorize such emergency treatment for your child, by completing this form; It is my understanding that the church will attempt to notify me in case of a medical emergency involving my child. If the church cannot reach me, then I authorize the church to hire a doctor or other health-care professional, and I give my permission to the doctor or other health-care professional to provide the medical services he or she may deem. I will pay for any medical expenses so incurred. I will notify the church if I feel there are any health considerations that would prevent my child's participation in any of the activities listed above. I also give my permission for the Kings Point Church of God Ministry's Leaders to restrict my child from participation in any activity which they have any question about for health or other reasons.
I have read, understand and agree with the Liability Release, Medical Release, Parental Consent and Medical Treatment Authorization. By typing my name I understand this is the act of a digital signature and release Kings Point Church of God from any and all liabilities.
I agree to the terms of this form.
(Parent(s) or Legal Guardian(s)
Date Format: MM slash DD slash YYYY